MAD covers medically necessary services and procedures for the diagnosis and treatment of an illness or injury as indicated by the eligible recipient's condition. Services must be furnished within the limits of MAD rules and within the scope of practice of the provider's professional standards. Public health services including services by public health nurses are covered to the same extent their services would be covered for non-IHS public health facilities. Limitations on covered services based on age and category of eligibility also apply to services rendered at an IHS or tribal 638 facility. Examples include enhanced benefits only available to early and periodic screening, diagnostic and treatment (EPSDT) eligible recipients, and limitations and enhanced services for alternative benefit plan (ABP) eligible recipients and eligible recipient pregnant women.
A. Outpatient encounters and visits: An outpatient encounter or visit is face-to-face contact between a practitioner and an eligible recipient as documented in the eligible recipient's physical or behavioral health record. An encounter or visit can occur at an IHS facility, tribal 638 facility, or a MAD recognized offsite location including IHS or tribal facility-based services that are provided in the home or in community centers or other locations but the medical records and the supervision or direction of the service comes from the eligible facility. To be billable as an encounter, the eligible recipient must be seen by a level of practitioner who would be eligible to be enrolled as a MAD provider or a practitioner comparable to that required by other service and provider rules or the service must be supervised by a level of practitioner who would be eligible to be enrolled as a MAD provider or a practitioner comparable to that required by other service and provider rules. Examples include but are not limited to the following: audiologist, behavioral health professional, certified nurse midwife, certified nurse practitioner, clinical nurse specialist, clinical pharmacy specialist, dentist, dental hygienist, licensed dietician, occupational therapist, optometrist, pharmacist clinician, physician assistant, physician, physical therapist, podiatrist, speech therapist and other provider types within their scope of practice as designated by MAD; see 8.310.2 NMAC...
