N.M. Code R. § 8.310.2.11 Service Limitations and Restrictions

• Library: New Mexico Administrative Code
• Edition: 2023
• Currency: Current through Register Vol. 34, No. 24, December 19, 2023
• Citation: N.M. Code R. § 8.310.2.11
• Year: 2023

MAD covers the following services with the frequency limits indicated. For purpose of this rule, a provider is considered part of the same provider group if he or she practices in the same office or clinic or has direct access to the MAP eligible recipient's medical or behavioral health records. Exceeding these limits requires prior authorization.

A. Office visits in a practitioner's office: Visits are limited to one-per-day from the same provider or provider group, unless the claim documents a change in the MAP eligible recipient's condition that could not have been anticipated at the first visit.

B. Physical medicine modalities in a professional practitioner's office: These modalities are limited to three-per-month. The limit is met when the same modality is performed three times during a calendar month, when three different modalities are performed during a month, or when three different modalities are performed during one visit.

C. Physical medicine procedures and kinetic activities in a professional practitioner's office: These services are limited to three-per-month from the same provider or provider group. The limit is met when the same procedure is performed three times during a calendar month, when three different procedures are performed during a month, or when three procedures are...