A.
Billing for services: MAD only makes payment to a provider or to
the following individuals or organizations for services:
(1) a government agency or third party with a
court order, based on a valid provider payment assignment; see 42 CFR Section
447.10(d)(e); or
(2) a business
agent, such as billing service or accounting firm that provides statements and
receives payment in the name of the provider; the agent's compensation must be
related to the cost of processing the claims and not based on a percentage of
the amount that is billed or collected or dependent upon collection of the
payment.
B.
Billing for services from group practitioners or employers of
practitioners: MAD may make payments to a group practice and to an
employer of an individual practitioner if the practitioner is required to turn
over his fees to the employer as a condition of employment. See 42 CFR
447.10(g) (2) (3). MAD may make payments to a facility where the services are
furnished or to a foundation, plan, or similar organization operating as an
organized health care delivery system if the facility, foundation, plan, or
organization is required by contract to submit claims for an individual
practitioner.
C.
Billing for
referral services: A referring provider must submit to the provider
receiving the referral, specimen, image, or other record, all information
necessary for the provider rendering the service to bill MAD within specified
time limits. An eligible recipient or their authorized representative or MAD is
not responsible for payment if the provider rendering the service fails to
obtain this information from the referring provider. Ordering, referring,
prescribing, rendering and attending providers must participate in a MCO or the
MAD (FFS) program, or otherwise be identifiable as a participating,
out-of-network, or in-network provider for services, as determined by
MAD.
D.
Hospital-based
services: For services that are hospital based, the hospital must
provide MAP recipient eligibility and billing information to providers of
services within the hospital, including professional components, hospital
emergency room (ER) physicians, hospital anesthesiologists, and other
practitioners for whom the hospital performs admission, patient registration,
or the patient intake process. An eligible recipient, member or his or her
authorized representative, or MAD is not responsible for payment if the
hospital-based provider does not obtain this information from the hospital as
necessary to bill within the specified time limits.
E.
Coordinated service
contractors: Some MAD services are managed by a coordinated service
contractor. Contracted services may include behavioral health services, dental
services, physical health services, transportation, pharmacy or other benefits
as designated by the MAD. The coordinated service contractor may be responsible
for any or all aspects of program management, prior authorization, (UR), claims
processing, and issuance of remittance advices and payments. A provider must
submit claims to the appropriate coordinated service contractor as directed by
MAD.
F.
Reporting of service
units: A provider must correctly report service units.
(1) For current procedural terminology (CPT)
codes or healthcare common procedural coding system (HCPCS) codes that describe
how units associated with time should be billed, providers are to follow those
instructions.
(2) For CPT or HCPCS
for services for which the provider is to bill 1 unit per 15 minute or per hour
of service, the provider must follow the chart below when the time spent is not
exactly 15 minutes or one hour.
time spent
|
number of 15-minute units that may be
billed
|
number of 1-hour units that may be
billed
|
Less than 8 minutes
|
0
services that are in their
entirety less than 8 minutes cannot be billed.
|
0
services that are in their entirety less than 8
minutes cannot be billed
|
8 minutes through 22 minutes
|
1
|
.25
|
23 minutes through 37 minutes
|
2
|
.5
|
38 minutes through 52 minutes
|
3
|
.75
|
53 minutes through 67 minutes
|
4
|
1
|
68 minutes through 82 minutes
|
5
|
1.25
|
83 minutes through 97 minutes
|
6
|
1.5
|
(3)
Only time spent directly working with an eligible recipient or member to
deliver treatment services is counted toward the time codes.
(4) Total time spent delivering each service
using a timed code must be recorded in the medical record of each eligible
recipient or member. If services provided are appropriately described by using
more than one CPT or HCPCS code within a single calendar day, then the total
number of units that can be billed is limited to the total treatment time.
Providers must assign the most units to the treatment that took the most
time.
(5) The units for codes do
not take precedence over centers for medicare and medicaid services (CMS)
national correct coding initiative (NCCI).
(6) Anesthesia units must be billed according
to
8.310.3 NMAC.
(7) Units billed
by a home and community-based services waiver provider, a behavioral health
provider, an early intervention provider, and all rehabilitation services
providers must also follow the requirements of this section unless exceptions
are specifically stated in published MAD program rules or provider billing
instructions.
G. MAD
requires co-payments for specific services under the medicaid managed care
program. The rules for medicaid managed care co-payments, including the
co-payment amounts, co-payment exemptions, provider responsibilities, and
member rights and responsibilities, are detailed at
8.308.14 NMAC.
H.
Billing state gross receipts
tax: For providers subject and registered to pay, gross receipts tax,
the provider may include gross receipt tax in the billed amount when the tax
applies to the item or service. The provider may only bill tax to the extent
the tax is also charged to the general public. A provider may not include gross
receipts tax in the billed amount when the provider is not obligated to pay
gross receipts tax to the state.