PROVIDERS

The Human Services Department mission is: To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.

Program Rules

Each of the program rules appear below along with an NMAC Number and a MAD Citation. The New Mexico Administrative Code (NMAC) Number serves as a link to the most current material for that rule. The MAD Citation, which sometimes refers to repealed or revised material, appears for reference purposes.

The NMAC rule numbers can be looked up on the NM Administrative Code website

Chapter 300 – Medicaid General Administration Policies

NMAC Number MAD Citation Policy Topic Effective Date
8.300.1 MAD 010 General Program Description 70
8.300.2  Health Insurance Portability and Accountability Act 1996 September 15, 2008
8.300.6 MAD 020 Responsibility and Delegation of Authority April 15, 2009
8.300.11 MAD 030 Confidentiality September 15, 2008
8.300.17 MAD 042 Conflict of Interest July 01, 2003
8.300.21  MAD 085 Medical Assistance Division Policy Apr 15, 2009
8.300.22 Electronic Health Records Incentive Program (Medicaid EHR)

 

Chapter 301 – Medicaid General Benefit Description

NMAC Number MAD Citation Policy Topic Effective Date
8.301.5 MAD 604 Medical Management Services
8.301.6 MAD 605 Client Medical Transportation Services

 

Chapter 302 – Medicaid General Provider Policies

NMAC Number MAD Citation Policy Topic Effective Date
8.302.1 MAD 701 General Provider Policies
8.302.2 MAD 702 Billing for Medicaid Services January 1, 2019
8.302.3 MAD 703 Third Party Liability Provider Responsibilities May 1, 2018
8.302.4 MAD 704 Out-of-State and Border Area Providers

 

Chapter 308 – Managed Care Program

NMAC Number Policy Topic Effective Date
8.308.2 Provider Network May 1, 2018
8.308.6 Eligibility January 1, 2019
8.308.7 Enrollment and Disenrollment January 1, 2019
8.308.8 Member Education May 1, 2018
8.308.9 Benefit Package January 1, 2019
8.308.10 Care Coordination January 1, 2019
8.308.11 Transition of Care May 1, 2018
8.308.12 Community Benefit January 1, 2019
8.308.13 Member Rewards May 1, 2018
8.308.14 Co-payments Oct 31, 2017
8.308.15 Grievances and Appeals May 1, 2018
8.308.20 Reimbursement January 1, 2014
8.308.21 Quality Management May 1, 2018
8.308.22 Fraud, Waste and Abuse January 1, 2014

 

Chapter 309 – Alternative Benefit Program

NMAC Number Policy Topic Effective Date
8.309.4   MAD Administrative Benefits and Limitation of Services Oct 1, 2014

 

Medical and Institutional Services and Providers

Chapter 310 – Health Care Professional Services

NMAC Number MAD Citation Policy Topic Effective Date
8.310.2 General Benefit Description January  1, 2014
8.310.3 Professional Providers, Services and Reimbursement January  1, 2014
8.310.4 MAD 713 Federally-Qualified Health Center Services
8.310.9 Rural Health Clinic Services January  1, 2014
8.310.10 Health Home Services April 1, 2016
8.310.12 Indian Health Services and Tribal 638 Facilities October 1, 2014

 

Chapter 311 – Hospital Services

NMAC        Number        MAD      Citation        Policy Topic Effective Date
8.311.2 MAD 721 Hospital Services
8.311.3 Methods and Standards for Establishing Payment In Patient Hospital Services January 1,2019
8.311.5 MAD 723 Swing Bed Hospital Services

 

Chapter 312 – Long -Term Care Services – Nursing Services

NMAC Number MAD Citation Policy Topic Effective Date
8.312.2 MAD 731 Nursing Facilities  August 1, 2014
8.312.3 MAD 731.d Cost-Related Reimbursement of Nursing Facilities

 

Chapter 313 – Long-Term Care Services: Intermediate Care Facilities

NMAC Number MAD Citation Policy Topic Effective Date
8.313.2 MAD 732 Intermediate Care Facilities for the Mentally Retarded
8.313.3 MAD 732.d Cost Related Reimbursement of ICF-MR Facilities

 

Chapter 314 – Home and Community Based Services Waivers & Providers

NMAC  Number MAD Citation Policy Topic Effective Date
8.314.2 MAD 733

Disabled and Elderly Home and Community-Based

Services Waiver

8.314.3 MAD 734

Medically Fragile Home and Community-Based

Services Waiver

 July 1, 2019
8.314.4 MAD 735

Aquired Immunodeficiency Syndrome (AIDS) or

AIDS-Related Condition Home and Community-Based

Services Waiver

 July 15, 2014
8.314.5 MAD 736 Developmental Disabilities Home and Community-Based   Services Waiver  December 1, 2018
8.314.6  Mi Via Home and Community-Based Services Waiver November 1, 2018
8.314.7 Supports Waiver April 1, 2021

 

Chapter 315 – Other Specialized Services & Providers

NMAC Number MAD Citation Policy Topic Effective Date
8.315.2 MAD 777 Program of All-Inclusive Care of the Elderly (PACE)

 

Chapter 320 – Early and Periodic Screening, Diagnosis & Treatment Services (EPSDT)

NMAC Number Policy Topic Effective Date
8.320.2 Early and Periodic Screening, Diagnosis and Treatment (EPSDT Services January 1, 2021
8.320.6 School-Based Services for Map Eligible Recipients Under Twenty-One Years of Age  July 1, 2015

 

Chapter 321 – Specialized Behavioral Health Services

NMAC Number MAD Citation Policy Topic Effective Date
8.321.2 Specialized Behavioral Health Provider Enrollment and Reimbursement  January 1, 2020

 

Chapter 324 – Adjunct Services

NMAC Number MAD Citation Policy Topic Effective Date
8.324.2 MAD 751 Laboratory Services
8.324.3 Diagnostic Imaging and Theraputic Radiology Services March 1, 2012
8.324.4 Pharmacy Services, Prescribing, and Practitioner Administered Drug Items January 1, 2014
8.324.5

 Vision Appliances, Hearing Appliances,

Durable Medical Equipment,

Oxygen, Medical Supplies, Prosthetics

and Orthotics

 January 1, 2014
8.324.7 Transportation Services and Lodging January 1, 2014
8.324.10 MAD 759 Ambulatory Surgical Center Services

 

Chapter 325 – Specialty Services

NMAC Number MAD Citation Policy Topic Effective Date
8.325.2 MAD 761 Dialysis Services
8.325.4 MAD 763 Hospice Care Services
8.325.8 Rehabilitation Service Providers March 1, 2012
8.325.9 MAD 768 Home Health Services
8.325.10 MAD 769 Emergency Medical Services for Aliens May 1, 2020

 

Chapter 326 – Case Management Services

NMAC Number MAD Citation Policy Topic Effective Date
8.326.2 MAD 771 Case Management for Adults with Developmental Disabilities
8.326.3 MAD 772 Case Management for Pregnant Women and their Infants
8.326.4 MAD 773 Case Management for the Chronically-Mentally ill
8.326.5 MAD 774 Case Management for Traumatically Brain-Injured Adults
8.326.6 MAD 775 Case Management for Services for Children up to Age Three
8.326.7 MAD 776 Adult Protective Services Case Management Services
8.326.8 MAD 778

Case Management Services for Children Provided by

Juvenile Probation & Parole Officers

8.326.10 Brain Injury Services Fund Program April 1, 2021

 

Chapter 349 – Coordinated Service Contractors

NMAC Number         MAD Citation Policy Topic Effective Date
8.349.2 Appeals and Grievance Process

 

Chapter 350 – Reconsideration of Utilization Review

NMAC Number MAD Citation Policy Topic Effective Date
8.350.2 MAD 953 Reconsideration of Utilization Review Decisions August 1, 2014
8.350.3 MAD 954 Abstract Submission for Level of Care Determinations
8.350.4 MAD 955 Reconsideration of Audit Settlements

 

Chapter 351 – Sanctions or Remedies

NMAC Number Policy Topic Effective Date
8.351.2 Sanctions and Remedies  January 1, 2014

 

Chapter 352 – Administrative Hearings

NMAC Number Policy Topic Effective Date
8.352.2 Claimant Hearings June 15, 2014
8.352.3 Provider Hearings January 1, 2014

 

Chapter 354 – Preadmission Screening & Annual Resident Review (PASRR) and Patient Status Policies

NMAC Number Policy Topic Effective Date
8.354.2 PASRR and Patient Status Hearing Policies August 1, 2014

 

Utilization Review Policies

NMAC Number Policy Topic Effective Date
8.310.7 Dental Services Utilization Review Instructions

 

Current Program Rules – Chapter 308 Managed Care Program

8.308.6 Eligibility and Enrollment

Current Program Rules – Chapter 349 – Coordinated Service Contractors

8.349.2 Appeals and Grievance Process

Current Program Rules – Chapter 350 – Reconsideration of Utilization Review

8.350.2 Reconsideration of Utilization Review Decisions

Archived Program Rules – Chapter 301 – Medicaid General Benefit Description

8.301.2 Medicaid General Benefit Description Eff 3/1/06

8.301.3 Medicaid General Non-Covered Services Eff 3/1/06

Archived Program Rules – Chapter 302 – Medicaid General Benefit Description

8.302.1 General Provider Policies

8.302.2 Billing for Medicaid Services

8.302.2 Billing for Medicaid Services 10/1/14

8.302.2 Billing for Medicaid Services 10/15/14 -9/30/17

8.302.2 NMAC Billing for Medicaid Services 1/1/14 – 10/14/14

8.302.2 NMAC Billing for Medicaid Services 1/1/14 -10/14/14

8.302.2 NMAC Billing for Medicaid Services 10/1/17 – 12/31/18

8.302.2 NMAC Billing for Medicaid Services 12/11/11 – 12/31/13

8.302.3 Third Party Liability Provider Responsibilities 5/1/04 – 4/30/18

8.302.4 Out-of-State and Border Area Providers

8.302.5 Prior Authorization & Utilization Review

Archived Program Rules – Chapter 305 – Mediciad Managed Care Policies

8.305.1 General Provisions

8.305.10 Encounters

8.305.11 Reimbursement for Managed Care

8.305.12 MCO Member Grievance Resolution

8.305.13 Fraud and Abuse

8.305.14 Reporting Requirements

8.305.15 Services of Children with Special Health Care Needs

8.305.16 Client Transition of Care

8.305.17 Value Added Services

8.305.2 Member Education

8.305.3 Contract Management

8.305.4 Managed Care Eligibility

8.305.5 Enrollment in Managed Care

8.305.6 Provider Networks

8.305.7 Benefit Package

8.305.8 Quality Management

8.305.9 Coordination of Services

Archived Program Rules – Chapter 306 – State Coverage Insurance

8.306.1 General Provisions

8.306.10 Encounters

8.306.11 Reimbursement

8.306.12 Member Greivance Resolution

8.306.13 Fraud and Abuse

8.306.14 Reporting Requirements

8.306.15 Services for SCI Members with Special Health Care Needs

8.306.16 Member Transition of Care

8.306.2 Member Education

8.306.3 Contract Management

8.306.4 Eligibility

8.306.5 Enrollment

8.306.6 Provider Networks

8.306.7 Benefit Package

8.306.8 Quality Management

8.306.9 Coordination of Benefits

8.308.13 Member Rewards

Archived Program Rules – Chapter 307 – Coordinated Long-Term Services

8.307.1 General Provisions

8.307.10 Encounters

8.307.11 Reimbursement

8.307.12 Member Grievance Resolution

8.307.13 Fraud and Abuse

8.307.14 Reporting Requirements

8.307.15 Services for Members with Special Health Care Needs

8.307.16 Client Transition of Care

8.307.17 Value Added Services

8.307.18 CoLTS 1915 (c) Home and Communit- Based Services Waiver

8.307.2 Member Education

8.307.3 Contract Management

8.307.4 Eligibility

8.307.5 Enrollment

8.307.6 Provider Networks

8.307.7 Benefits Package

8.307.8 Quality Management

8.307.9 Coordination of Services

Archived Program Rules – Chapter 308 Managed Care Program

8.308.10 Care Coordination 5/1/18 – 12/31/18

8.308.12 Community Benefit 3/1/17 – 12/13/18

8.308.12 Community Benefits – 8/1/14 – 2/28/17

8.308.6 Eligibility 5/1/18 – 12/31/18

8.308.7 Enrollment and Disenrollment 5/1/18 – 12/31/18

8.308.9 Benefit Package 5/1/18 – 12/31/18

Archived Program Rules – Chapter 310 – Health Care Professional Services

8.310.10 Health Home Services 4/1/16 – 4/29/18

8.310.10 MAD 718.1 Midwife Services

8.310.11 Podiatry Services

8.310.13 Telehealth Services

8.310.15 Intensive Out Patient Services

8.310.2 Medical Services Providers

8.310.3 Rural Health Clinic Services

8.310.5 Anesthesia Services

8.310.6 Vision Care Services

8.310.7 Dental Services

8.310.8 Behavioral Health Professional Services

Archived Program Rules – Chapter 311 – Hospital Services

8.311.3 Methods and Standards for Establishing Payment – IHS 1/1/18 – 12/31/18

8.311.3 Methods and Standards for Establishing Payment – IHS 6/1/12 – 5/31/16

8.311.3 Methods and Standards for Establishing Payment – IHS 6/1/16 – 12/26/17

8.311.4 MAD 722 Outpatient Psychiatric Services and Partial Hospitalization

Archived Program Rules – Chapter 314 – Home and Community-Based Services Waivers & Providers

8.314.3 Medically Fragile Home and Community – Based Services Waiver 3/1/18 – 6/30/19

8.314.3 Medically Fragile Home and Community-Based Services Waiver 12/1/10 – 2/28/18

8.314.5 Developmental Disabilities Home and Community-Based Services Waiver 03/01/16-11/30/18

8.314.5 Developmental Disabilities Home and Community-Based Services Waiver 2/1/15-2/29/16

8.314.5 Developmental Disabilities Home and Community-Based Waiver

8.314.5 NMAC with Index

8.314.6 Mi Via Home and Community-Based Services Waiver

8.314.6 Mi Via Home and Community-Based Services Waiver 2/14/14 – 2/29/16

8.314.6 Mi Via Home and Community-Based Services Waiver 3/1/16 – 10/31/18

Archived Program Rules – Chapter 315 – Other Specialized Services and Providers

8.315.3 Psychosocial Rehabilitation Services

8.315.4 Personal Care Option (PCO) Services

8.315.5 Assertive Community Treatment (ACT) Services

8.315.6 Comprehensive Community Support Services

Archived Program Rules – Chapter 320 – Early and Periodic Screening, Diagnosis and Treatment

8.320.2 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services 2/1/20 to 12/31/20

8.320.6 School-Based Services for MAP Eligible Recipients Under Twenty-One Years of Age 7/1/15 to 1/31/20

8.320.2 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services 1/1/2014 to 1/31/2020

8.320.3 Tot-To-Teen Health Check

8.320.4 Special Rehabilitation Services

8.320.5 EPSDT Case Management

8.320.6 School Based Services for Recipients Under 21 Years of Age

Archived Program Rules – Chapter 321 – Specialized Behavioral Health Services

8.321.2 Inpatient Psychiatric Care in Freestanding Psychiatric Hospital

8.321.2 Specialized Behavioral Health Provider Enrollment and Reimbursement

8.321.3 Accredited Residential Treatment Center Services

8.321.4 Non-Accredited Residential Treatment Centers and Group Homes

8.321.5 Outpatient and Patial Hospitalization Services in Freestanding Psychiatric Hospitals

Archived Program Rules – Chapter 322 – Enhanced EPSDT: Community Mental Health Services

8.322.2 Treatment Foster Care

8.322.3 MAD 745.2 Behavior Management Skills Development Services

8.322.4 MAD 745.3 Day Treatment

8.322.5 Treatment Foster Care II

8.322.6 Multi-Systematic Therapy Services

Archived Program Rules – Chapter 323 – Enhanced EPSDT: Out-Patient Providers

8.323.2 EPSDT Personal Care Services

8.323.3 MAD 746.6 Licensed Alcohol and Drug Abuse Counselors

8.323.4 EPSDT Private Duty Nursing Services

8.323.5 EPSDT Rehabilitation Services

Archived Program Rules – Chapter 324 – Adjunct Services

8.324.3 Diagnostic Imaging an Therapeutic Radiology Services

8.324.4 Pharmacy Services

8.324.5 Durable Medical Equipment and Medical Supplies

8.324.6 Hearing Aids and Related Evaluations

8.324.7 Transportation Services

8.324.8 Prosthetics and Orthotic

8.324.9 Nutrition Services

Archived Program Rules – Chapter 325 – Specialty Services

8.325.10 Emergency Medical Services for Aliens

8.325.11 Medication Assisted Treatment for Opioid Addiction

8.325.3 MAD 762 Reproductive Health Services

8.325.5 Transplant Services

8.325.6 Experimental or Investigational Procedures, Technologies or Non-Drug Therapies

8.325.7 Pregnancy Termination Procedures

8.325.8 Rehabilitation Service Providers

Archived Program Rules – Chapter 351 – Sanctions or Remedies

8.351.2 Sanctions and Remedies

Archived Program Rules – Chapter 352 – Recipient Hearing Policies

8.352.2 Recipient Hearings

8.352.3 Provider Hearings

Archived Program Rules – Chapter 353 – Provider Hearing Policies

8.353.2 Provider Hearings

Archived Program Rules – Chapter 354 – Preadmission Screening and Annual Review (PASSR) and Patient Status Policies

8.354.2 PASRR and Patient Status Hearing Policies

Archived Utilization Review Policies

8.312.2 UR Long Term Care Utilization Review for Nursing Facilities