Providers must be enrolled as Medicaid providers before submitting claims for payment to Conduent, the New Mexico Medicaid Fiscal Agent. The MAD Benefits Bureau is responsible for enrolling Medicaid fee-for-service providers, with the exception of intermediate care facilities, personal care agencies, nursing home facilities (enrolled by the MAD Program Planning Bureau), and presumptive eligibility determiners (enrolled by MAD Client Services Bureau.)
According to Medical Assistance Division (MAD) policy 701.1, upon approval of a New Mexico Medical Assistance Provider Participation Agreement (PPA) by MAD, licensed practitioners or facilities that meet applicable requirements are eligible to be reimbursed for covered services rendered to Medicaid recipients.
Fee for Service Frequently Asked Questions (FAQs)
Using the NEW MEXICO Medicaid Fee Schedule
1. The Medicaid Fee Schedule is intended to be a helpful pricing guide for providers of services. It is not to be used as a guide to coverage of services by the Medicaid Program for any individual client or groups of clients. Benefits available to Medicaid clients may vary depending on the Category of Eligibility or age of a client. Likewise, some services may be limited in the type or specialty of the provider who can be paid for a service.
2. While every attempt has been made to assure the fee schedule is accurate, in the event of error or subsequent change of a fee, the pricing policies of the Medicaid Program will prevail rather than this fee schedule.
3. Some services are further limited in payment, as specified in the Medicaid Program Policies. A partial list is as follows:
- Services commonly performed in an office setting, when performed in a hospital based setting, may be limited to 60% of the fee schedule amount.
- Some providers may be limited to a percentage of the rate. For example, a certified nurse practitioner billing independently is limited to 90% of the fee of a physician practitioner.
- Professional components for radiology may be limited to not more than 40% of a complete procedure.
- When physician surgical assistants are allowed for surgical procedures, payment is limited to 20% of the surgical procedure.
- Multiple surgical procedures performed at the same time may be reduced in payment. Bilateral procedures and incidental procedures are also subject to special payment and reimbursement policies.The fee for some services may include payment for other services; for example, payment for surgical procedures may include hospital visits and/or follow up care or supplies which are not paid separately.
- Reimbursement is limited to the lesser of the provider’s usual and customary charge or the fee schedule amount for the service. For some services, the provider may not bill more than an invoice cost or invoice cost plus a percentage. Refer to program policy and billing instructions. For some equipment and supplies, the fee schedule may indicate “subject to review” rather than a fee, or “bill invoice cost plus %”. The provider should refer to the Medicaid Program Policy manuals and/or billing instructions on billing for these services.
- Reimbursement may differ from the fee schedule depending on the modifier billed to further identify the service or due to the type of provider rendering the service. Some of these differences are listed on a “Special Reimbursement” table.
4. Some services may require prior authorization; may be limited in number, scope, or frequency of service or coverage; may be subject to review prior to payment; or may otherwise require justification to ensure the medical necessity of the service. Payments for all Medicaid services are based upon the principle that the service is medically necessary. If the service is determined not to be medically necessary, payment may not be made or may be recouped.
5. This Medicaid Fee Schedule is not intended for use by anesthesia providers, institutional providers, or other providers or services not reimbursed on a fee schedule basis such as federally qualified health centers, rural health clinics, ambulatory surgical centers, most Indian Health Service facilities services, etc.
For details and application of these and other limitations, refer to the Medicaid Program Policies.
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