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Medicaid Enrollment Guidelines


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 Human Service Department (HSD) 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 HSD

  • 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.

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