Medical Assistance Division Rules and Billing Overview
Medicaid Providers are responsible for complying with all instructions, directives, billing, reimbursement, audit, recoupment, and withholding provisions made available by the Human Services Department (HSD) and its authorized agents.
Providers are also responsible for obtaining, maintaining, and keeping updated program rules and instructions on billing and utilization review and other pertinent material made available by HSD and its authorized agents through mailings and as found on this website.
- The New Mexico Administrative Code (NMAC) is collection of formal rules that New Mexico State agencies and departments publish about the programs that they run. Simply put, rules are a special category of law written by state agencies to support, clarify, or implement specific laws enacted by the legislature called statutes. State rules can include building codes, air quality standards, tax codes, public assistance regulations, and public health regulations, to name but a few. They are subordinate to statutes and must work within the framework established by statute. A defining aspect of rules is that they affect people or other agencies outside the agency that writes them.
The state rules that govern the NM Medicaid program are found in Title 8, Social Services, of the NMAC. This section is commonly called the ‘policy manual’ but is more formally referred to as the rules.
To go to an on-line version of the relevant chapters of the NMAC, click here.
For rule changes that are in process, please refer to the ‘Notices of Rulemaking’ section of the NM Medical Assistance Division (MAD) website, which can be found here.
Public notices of rule changes and their associated public hearings are published in the New Mexico Register, published by The Administrative Law Division of The Commission of Public Records, and the following newspapers: the Las Cruces Sun, and the Albuquerque Journal.
For more information on the rulemaking and promulgation process, please click here.
- The Medical Assistance Division (MAD) has issued a number of billing instruction documents for fee-for-service (FFS) providers which can be viewed on the MAD website and serve as instructions when billing the Medicaid program. These documents contain a host of important information regarding specific Medicaid programs.
- MAD also regularly issues Supplements to the rules that serve to inform providers on various important issues. These are both mailed directly to providers (as selected by topic) and are also posted on the MAD website. Providers are encouraged to regularly check this section of the website for recently released supplements.
- MAD utilizes behavioral health service definitions and crosswalk documents that help define certain behavioral health services. These documents can be found by clicking here.
Managed Care Policy Manual
*It is important to note that each Centennial Care Managed Care Organization (MCO) must be consulted for their own policy and other guidance documents for both recipients and providers. Please click here for more information about Managed Care Organizations.