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.
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.
LICENSE FOR USE OF “Physicians’ CURRENT PROCEDURAL TERMINOLOGY” (CPT) Agreement:
CPT codes, descriptions and other data are copyright 1999 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA. You, your employees and agents are authorized to use CPT only as contained in the following authorized materials: Local Medical Review Policies (LMRPs), Bulletins/Newsletters, Program Memoranda and Instructions, Coverage Issues and Medicare Coding Policies, Program Integrity Bulletins and Information, Educational Training Materials, including Computer Basic Training Modules, Fee Schedules, Special Mailings internally within your organization within the United States for the sole use by yourself, employees and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of Ambulatory Surgical Centers for resale and/or license, transferring copies of Ambulatory Surgical Centers to any party not bound by this agreement, creating any modified or derivative work of Ambulatory Surgical Centers, or making any commercial use of Ambulatory Surgical Centers. License to use Ambulatory Surgical Centers for any use not authorized here in must be obtained through the AMA, Ambulatory Surgical Centers Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA web site, http://www.ama-assn.org/Ambulatory Surgical Centers. Applicable FARS/DFARS restrictions apply to government use.
U.S. Government Rights
This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.
AMA Disclaimer of Warranties and Liabilities.
CPT is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with the New Mexico Medicaid Program and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.
The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the Ambulatory CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.
Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the link labeled “Agree”.