N.M. Code R. § 8.310.4.15 Reimbursement

• Library: New Mexico Administrative Code
• Edition: 2023
• Currency: Current through Register Vol. 34, No. 24, December 19, 2023
• Citation: N.M. Code R. § 8.310.4.15
• Year: 2023

FQHCs must submit claims for reimbursement on the UB-92 claim form or its successor. See 8.302.2 NMAC, Billing for Medicaid Services [MAD-702]. Once enrolled, providers receive instructions on documentation, billing, and claims processing. Interim reimbursement for services provided by an FQHC is made by MAD based on submitted claims.

A. Initial rates: The initial interim rate for new FQHC providers will be the interim rate set by medicare.

B. Cost settlement:

(1) FQHCs must submit cost reports on an annual basis to MAD or its designee within the time frames specified by medicare. FQHCs will not be granted an extension to the cost report filing time frames.

(2) A final cost settlement based on the audit data will be made in accordance with delineated medicaid requirements and/or applicable medicare cost reimbursement principles when medicaid requirements are not specified. Final cost settlements are based on the allowable cost as audited or desk reviewed costs by MAD or its designee. "Allowable costs" are costs incurred by an FQHC which are reasonable in amount, proper and necessary for the efficient delivery of services by the FQHC (MAD or its designee will follow the HCFA Pub. 15-1 in determining allowable costs). The supporting documentation for "allowable costs" must be available upon request from MAD or its designee.

(3) MAD or its designee may reopen cost reports per HCFA Pub. 15-1 Section 2931 through 2932.1. Providers will be notified on a case-by-case basis thirty (30) days prior to any reopening. MAD uses the productivity standards used in the medicare cost report. However, MAD does not use the costs limits imposed by medicare. If an FQHC disagrees with an audit settlement, the provider can request a reconsideration. See 8.350.4 NMAC Reconsideration of Audit Settlement [MAD-955].

(4) HSD or its designee will complete their initial review of cost settlement materials within 150 days of the receipt of all required information.

C. What constitutes a visit: A visit is a face-to-face encounter between a center client and a physician, physician assistant, nurse practitioner, nurse midwife, visiting nurse, qualified clinical psychologist or qualified clinical social worker. Encounters with more than one health professional and multiple encounters with the same...