N.M. Code R. § 8.310.12.15 Reimbursement
Library | New Mexico Administrative Code |
Edition | 2023 |
Currency | Current through Register Vol. 34, No. 24, December 19, 2023 |
Citation | N.M. Code R. § 8.310.12.15 |
Year | 2023 |
OMB rates are published annually in the federal register and are applicable to an IHS and a tribal 638 facility. These rates are applied retroactively to their effective date.
A. IHS OMB outpatient and inpatient reimbursement rates include facility fees and professional fees except as described in this rule.
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(1) Outpatient
encounters and visits: MAD reimburses outpatient encounters and visits at the
OMB outpatient encounter rate. Reimbursement at OMB rates is retroactive to the
dates of service for which the OMB rates are applicable.
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(2) Inpatient hospital service: MAD
reimburses covered inpatient hospital stays at the federally published OMB
hospital inpatient per diem rate. The inpatient OMB rate applies when an
eligible recipient has been under outpatient care observation or is receiving
extended outpatient medical services, and the time period has been for 24 hours
or more whether the eligible recipient has been formally admitted or not. Risk
factors such as distance of the facility from the eligible recipient's
residence for potential emergency follow up care, as well as lack of
availability of step-down care providers (home health services, nursing
facilities, and acute long term care hospital facilities) may be considered in
making discharge decisions regarding the eligible recipient. Alternatively, the
facility may elect to bill a daily outpatient OMB rate for an eligible
recipient under observation. Reimbursement at OMB rates is retroactive to the
date of service for which the federal OMB rates are applicable.
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(3) Reimbursement following medicare payment
is made at the full copayment, deductible and co-insurance amounts determined
by medicare. Reimbursement following payment by other insurance is made at the
OMB rate, is applicable, less the payment received from the other
insurer.
B. Services not subject to the OMB rates are reimbursed according to MAD rules for the...
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