Medicaid Enrollment Guidelines
The Affordable Care Act (ACA) and Title 42, Part 455 of the Code of Federal Regulations require attending, ordering, referring, rendering and prescribing providers to enroll in the New Mexico Medicaid program. These requirements are designed to ensure that all attended, prescribed, ordered, referred or rendered services, items and admissions for Medicaid beneficiaries originate from properly licensed providers who have not been excluded from Medicare or Medicaid.
A provider who is enrolled as only a managed care provider or a fee-for-service (FFS) provider, or who is enrolled as both a managed care and FFS provider, must enroll with Medicaid. Most services and items will only be paid by the Medicaid program if the individual provider who attends, prescribes, orders, refers, or renders a service or item is identified on the claim and is enrolled in the Medicaid program. Otherwise, the claim will be denied in accordance with federal requirements.
Effective Feb. 1, 2018: The Centers for Medicare & Medicaid Services (CMS) extended these same requirements to claims filed with Medicaid managed care organizations (MCOs).
Providers who need to enroll with the Medicaid program should visit the New Mexico Medicaid Portal
Providers who need verify their enrollment should visit the verification tool
Requirements for Reporting Rendering, Ordering and Referring Providers on Claims
The Medical Assistance Division (MAD) of the New Mexico Health Care Authority (HCA) requires providers to include information on claims related to the rendering, ordering and referring providers. Rendering providers must be reported on professional services, including on laboratory, radiology, injections, supplies, items and virtually all other services reported on a CMS-1500 claim form.
Even when a lab or radiology code or other service codes on the claim are performed by a technician, nurse or other staff, the provider overseeing the primary service for the recipient must be reported as the rendering provider for these types of services. Rendering providers may either be reported at the header level if a single provider is the rendering provider, or they may be reported at the line level. All claims for payment for items and services must contain the National Provider Identifier (NPI) of the provider or other professional who rendered, ordered or referred such items or services.
In many hospitals, the rendering provider may be a resident, an intern or a supervised nurse, technician or other individual who is not typically enrolled as a provider in their own right. In these situations, the supervising provider may be considered the rendering provider and reported as such.
Note: Presbyterian rejects and deny claims when:
The individual and group provider are not enrolled with the HCA
Providers are not enrolled with the appropriate provider type
Providers bill codes outside of their enrolled provider type
Presbyterian is recouping payments when:
Providers have not enrolled with New Mexico Medicaid
Providers enrolled with an inaccurate provider type and billed codes for which they are not enrolled within the past year
Presbyterian uses the MAD approval date on the Medicaid file to determine timely filing.
Helpful Resources
Enroll, verify enrollment status, confirm enrolled provider type or enroll for additional provider types on the New Mexico Medicaid Portal
Hospitals, outpatient hospitals, home health agencies, hospices, nursing facilities, intermediate care facilities for individuals with an intellectual disability or related conditions (ICF/IIDs) and residential providers (ARTCs, RTCs and group homes) should review MAD Supplement 17-07
Clinical labs, diagnostic labs, radiology facilities and radiation treatment centers; providers of hearing aids and supplies, glasses, IV infusions, medical supplies and medical equipment; occupational therapists, physical therapists, speech and language therapists and pathologists, and rehabilitation centers should review MAD Supplement 17-08
All other providers should review MAD Supplement 17-09
Review state billing guidelines
Review the New Mexico Administrative Code (NMAC) program rules
Review the supplements to MAD NMAC program rules
