New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 350 - RECONSIDERATION OF UTILIZATION REVIEW
Part 3 - ABSTRACT SUBMISSION FOR LEVEL OF CARE DETERMINATIONS
Section 8.350.3.10 - REQUESTS FOR RETROACTIVE PRIOR APPROVAL REVIEW

Universal Citation: 8 NM Admin Code 8.350.3.10

Current through Register Vol. 35, No. 18, September 24, 2024

MAD permits facilities to request retroactive prior approval review of long-term care abstracts which are not submitted for level-of-care reviews within the applicable time period if certain conditions are met.

A. Initial abstracts: Facilities must submit a request for retroactive prior approval review when delays in the submission of an initial abstract beyond the ten (10) working day period are caused by circumstances beyond the facility's control, including:

(1) physician does not sign orders or history and physical within the time period; or

(2) medicaid eligibility decisions have not been completed.

B. Initial continued-stay abstract: Facilities must submit a request for retroactive prior approval review when continued-stay abstracts are not submitted at least ten (10) working days before the expiration of the currently certified length of stay. The delay in submission must be attributed to circumstances beyond the facility's control.

C. Subsequent continued-stay abstract: Facilities must submit a request for retroactive prior approval review when subsequent continued-stay abstracts are not submitted at least ten (10) working days prior to the expiration of the currently certified length of stay. The delay in submission must be caused by circumstances beyond the facility's control.

D. Delays caused by circumstances within the facility's control: Medicaid allows its UR contractor to accept ten (10) total late abstracts per facility per calendar year when delays in submission are caused by circumstances within the control of the facility, such as staff illness or staff turnover. Initial admission abstracts and initial and subsequent continued stay abstracts are included in this number.

E. Denial of request for retroactive prior approval reviews: Medicaid does not reimburse facilities for dates of service not covered by an approved abstract. Facilities cannot bill medicaid recipients for those days.

Disclaimer: These regulations may not be the most recent version. New Mexico may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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