N.M. Code R. § 8.308.9.10 - MEDICAL ASSISTANCE DIVISION PROGRAM RULES
New Mexico administrative code (NMAC) rules and related documents contain a detailed description of the services covered by MAD, the limitations and exclusions to covered services, and non-covered services. The NMAC rules are the official source of information on covered and non-covered services. Unless otherwise directed, the MCO shall determine its own utilization management (UM) protocols and shall comply with state and federal requirements for UM including, but not limited to 42 CFR Part 456, which is based on reasonable medical evidence. The MCO shall comply with the most rigorous standards or applicable provisions of either NCQA, HSD regulation, the Balanced Budget Act of 1997, or 42 CFR Part 438 related to timeliness of decisions. The MCO shall ensure that medicaid covered benefits are furnished in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to beneficiaries pursuant to 42 CFR 440.230. MAD may review and approve the MCO's UM protocols. Unless otherwise directed by MAD, a HSD contracted MCO is not required to follow MAD's reimbursement methodologies or MAD's fee schedules unless otherwise required in a NMAC rule. The MCO shall comply with 42 CFR Parts 438, 440, and 456.
Notes
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