PROVIDERS
The Health Care Authority’s mission is: We ensure that New Mexicans attain their highest level of health by providing whole-person, cost-effective, accessible, and high-quality health care and safety-net services.
Program Rules
Each of the program rules appear below along with an NMAC Number and a MAD Citation. The New Mexico Administrative Code (NMAC) Number serves as a link to the most current material for that rule. The MAD Citation, which sometimes refers to repealed or revised material, appears for reference purposes.
The NMAC rule numbers can be looked up on the NM Administrative Code website
Chapter 300 – Medicaid General Administration Policies
| NMAC Number | MAD Citation | Policy Topic | Effective Date |
| 8.300.1 | MAD 010 | General Program Description 70 | September 15, 2008 |
| 8.300.2 | — | Health Insurance Portability and Accountability Act 1996 | September 15, 2008 |
| 8.300.6 | MAD 020 | Responsibility and Delegation of Authority | April 15, 2009 |
| 8.300.11 | MAD 030 | Confidentiality | September 15, 2008 |
| 8.300.17 | MAD 042 | Conflict of Interest | July 01, 2003 |
| 8.300.21 | MAD 085 | Medical Assistance Division Policy | Apr 15, 2009 |
| 8.300.22 | — | Electronic Health Records Incentive Program (Medicaid EHR) | July 1, 2012 |
Chapter 301 – Medicaid General Benefit Description
| NMAC Number | MAD Citation | Policy Topic | Effective Date |
| 8.301.5 | MAD 604 | Medical Management Services | July 1, 2001 |
| 8.301.6 | MAD 605 | Client Medical Transportation Services | March 1, 2011 |
Chapter 302 – Medicaid General Provider Policies
| NMAC Number | MAD Citation | Policy Topic | Effective Date |
| 8.302.1 | MAD 701 | General Provider Policies | January 1, 2023 |
| 8.302.2 | MAD 702 | Billing for Medicaid Services | January 1, 2019 |
| 8.302.3 | MAD 703 | Third Party Liability Provider Responsibilities | May 1, 2018 |
| 8.302.4 | MAD 704 | Out-of-State and Border Area Providers | November 1, 2010 |
Chapter 308 – Managed Care Program
| NMAC Number | Policy Topic | Effective Date |
| 8.308.2 | Provider Network | May 1, 2018 |
| 8.308.6 | Eligibility | August 10, 2021 |
| 8.308.7 | Enrollment and Disenrollment | August 10, 2021 |
| 8.308.8 | Member Education | May 1, 2018 |
| 8.308.9 | Benefit Package | April 5, 2022 |
| 8.308.10 | Care Coordination | January 1, 2019 |
| 8.308.11 | Transition of Care | April 5, 2022 |
| 8.308.12 | Community Benefit | January 1, 2019 |
| 8.308.13 | Member Rewards | May 1, 2018 |
| 8.308.14 | Co-payments | October 1, 2017 |
| 8.308.15 | Grievances and Appeals | May 1, 2018 |
| 8.308.20 | Reimbursement | April 5, 2022 |
| 8.308.21 | Quality Management | May 1, 2018 |
| 8.308.22 | Fraud, Waste and Abuse | January 1, 2014 |
Chapter 309 – Alternative Benefit Program
| NMAC Number | Policy Topic | Effective Date |
| 8.309.4 | MAD Administrative Benefits and Limitation of Services | October 15, 2014 |
Medical and Institutional Services and Providers
Chapter 310 – Health Care Professional Services
| NMAC Number | MAD Citation | Policy Topic | Effective Date |
| 8.310.2 | — | General Benefit Description | August 10, 2021 |
| 8.310.3 | — | Professional Providers, Services and Reimbursement | January 1, 2023 |
| 8.310.4 | MAD 713 | Federally-Qualified Health Center Services | November 1, 2004 |
| 8.310.9 | — | Rural Health Clinic Services | January 1, 2014 |
| 8.310.10 | Health Home Services | April 1, 2016 | |
| 8.310.12 | — | Indian Health Services and Tribal 638 Facilities | November 1, 2014 |
Chapter 311 – Hospital Services
| NMAC Number | MAD Citation | Policy Topic | Effective Date |
| 8.311.2 | MAD 721 | Hospital Services | February 1, 2012 |
| 8.311.3 | Methods and Standards for Establishing Payment In Patient Hospital Services | September 1, 2021 | |
| 8.311.5 | MAD 723 | Swing Bed Hospital Services | March 1, 2012 |
Chapter 312 – Long -Term Care Services – Nursing Services
| NMAC Number | MAD Citation | Policy Topic | Effective Date |
| 8.312.2 | MAD 731 | Nursing Facilities | August 1, 2014 |
| 8.312.3 | MAD 731.D | Cost-Related Reimbursement of Nursing Facilities | September 1, 2021 |
Chapter 313 – Long-Term Care Services: Intermediate Care Facilities
| NMAC Number | MAD Citation | Policy Topic | Effective Date |
| 8.313.2 | MAD 732 | Intermediate Care Facilities for the Mentally Retarded | May 1, 2007 |
| 8.313.3 | MAD 732.D | Cost Related Reimbursement of ICF-MR Facilities | September 1, 2002 |
Chapter 314 – Home and Community Based Services Waivers & Providers
| NMAC Number | MAD Citation | Policy Topic | Effective Date |
| 8.314.3 | MAD 734 |
Medically Fragile Home and Community-Based Services Waiver |
July 1, 2019 |
| 8.314.5 | MAD 736 | Developmental Disabilities Home and Community-Based Services Waiver | April 1, 2024 |
| 8.314.6 | — | Mi Via Home and Community-Based Services Waiver | November 1, 2018 |
| 8.314.7 | — | Supports Waiver | April 1, 2021 |
Chapter 315 – Other Specialized Services & Providers
| NMAC Number | MAD Citation | Policy Topic | Effective Date |
| 8.315.2 | MAD 777 | Program of All-Inclusive Care of the Elderly (PACE) |
Chapter 320 – Early and Periodic Screening, Diagnosis & Treatment Services (EPSDT)
| NMAC Number | Policy Topic | Effective Date |
| 8.320.2 | Early and Periodic Screening, Diagnosis and Treatment (EPSDT Services | January 1, 2021 |
| 8.320.6 | School-Based Services for Map Eligible Recipients Under Twenty-One Years of Age | July 1, 2022 |
Chapter 321 – Specialized Behavioral Health Services
| NMAC Number | MAD Citation | Policy Topic | Effective Date |
| 8.321.2 | — | Specialized Behavioral Health Provider Enrollment and Reimbursement | March 1, 2023 |
Chapter 324 – Adjunct Services
| NMAC Number | MAD Citation | Policy Topic | Effective Date |
| 8.324.4 | — | Pharmacy Services, Prescribing, and Practitioner Administered Drug Items | January 1, 2014 |
| 8.324.5 | — |
Vision Appliances, Hearing Appliances, Durable Medical Equipment, Oxygen, Medical Supplies, Prosthetics and Orthotics |
January 1, 2014 |
| 8.324.7 | — | Transportation Services and Lodging | January 1, 2014 |
| 8.324.10 | MAD 759 | Ambulatory Surgical Center Services |
Chapter 325 – Specialty Services
| NMAC Number | MAD Citation | Policy Topic | Effective Date |
| 8.325.2 | MAD 761 | Dialysis Services | |
| 8.325.4 | MAD 763 | Hospice Care Services | |
| 8.325.8 | Rehabilitation Service Providers | March 1, 2012 | |
| 8.325.9 | MAD 768 | Home Health Services | |
| 8.325.10 | MAD 769 | Emergency Medical Services for Non-Citizens | January 1, 2022 |
| 8.325.12 | Medication Assisted Treatment Services in Correctional Facilities | September 1, 2024 |
Chapter 326 – Case Management Services
| NMAC Number | MAD Citation | Policy Topic | Effective Date |
| 8.326.2 | MAD 771 | Case Management for Adults with Developmental Disabilities | |
| 8.326.3 | MAD 772 | Case Management for Pregnant Women and their Infants | April 5, 2022 |
| 8.326.4 | MAD 773 | Case Management for the Chronically-Mentally ill | |
| 8.326.5 | MAD 774 | Case Management for Traumatically Brain-Injured Adults | |
| 8.326.6 | MAD 775 | Case Management for Services for Children up to Age Three | |
| 8.326.7 | MAD 776 | Adult Protective Services Case Management Services | |
| 8.326.8 | MAD 778 |
Case Management Services for Children Provided by Juvenile Probation & Parole Officers |
|
| 8.326.10 | Brain Injury Services Fund Program | April 1, 2021 |
Chapter 349 – Coordinated Service Contractors
| NMAC Number | MAD Citation | Policy Topic | Effective Date |
| 8.349.2 | — | Appeals and Grievance Process |
Chapter 350 – Reconsideration of Utilization Review
| NMAC Number | MAD Citation | Policy Topic | Effective Date |
| 8.350.2 | MAD 953 | Reconsideration of Utilization Review Decisions | August 1, 2014 |
| 8.350.3 | MAD 954 | Abstract Submission for Level of Care Determinations | |
| 8.350.4 | MAD 955 | Reconsideration of Audit Settlements |
Chapter 351 – Sanctions or Remedies
| NMAC Number | Policy Topic | Effective Date |
| 8.351.2 | Sanctions and Remedies | January 1, 2014 |
Chapter 352 – Administrative Hearings
| NMAC Number | Policy Topic | Effective Date |
| 8.352.2 | Claimant Hearings | June 15, 2014 |
| 8.352.3 | Provider Hearings | January 1, 2014 |
Chapter 354 – Preadmission Screening & Annual Resident Review (PASRR) and Patient Status Policies
| NMAC Number | Policy Topic | Effective Date |
| 8.354.2 | PASRR and Patient Status Hearing Policies | August 1, 2014 |
Utilization Review Policies
| Policy Topic | Effective Date |
| UR Health Care Professional Services – Dental Services | February 15, 2010 |
Current Program Rules – Chapter 308 Managed Care Program
8.308.6 Eligibility and Enrollment
Current Program Rules – Chapter 349 – Coordinated Service Contractors
8.349.2 Appeals and Grievance Process
Current Program Rules – Chapter 350 – Reconsideration of Utilization Review
8.350.2 Reconsideration of Utilization Review Decisions
Archived Program Rules – Chapter 301 – Medicaid General Benefit Description
8.301.2 Medicaid General Benefit Description 3/1/06
8.301.3 Medicaid General Non-Covered Services 3/1/06
8.302.1 Medicaid General Benefit Description 9/15/08 to 12/31/22
Archived Program Rules – Chapter 302 – Medicaid General Benefit Description
8.302.1 General Provider Policies
8.302.2 Billing for Medicaid Services
8.302.2 Billing for Medicaid Services 10/1/14
8.302.2 Billing for Medicaid Services 10/15/14 -9/30/17
8.302.2 NMAC Billing for Medicaid Services 1/1/14 – 10/14/14
8.302.2 NMAC Billing for Medicaid Services 1/1/14 -10/14/14
8.302.2 NMAC Billing for Medicaid Services 10/1/17 – 12/31/18
8.302.2 NMAC Billing for Medicaid Services 12/11/11 – 12/31/13
8.302.3 Third Party Liability Provider Responsibilities 5/1/04 – 4/30/18
8.302.4 Out-of-State and Border Area Providers
8.302.5 Prior Authorization & Utilization Review
Archived Program Rules – Chapter 305 – Medicaid Managed Care Policies
8.305.11 Reimbursement for Managed Care
8.305.12 MCO Member Grievance Resolution
8.305.14 Reporting Requirements
8.305.15 Services of Children with Special Health Care Needs
8.305.16 Client Transition of Care
8.305.4 Managed Care Eligibility
8.305.5 Enrollment in Managed Care
8.305.9 Coordination of Services
Archived Program Rules – Chapter 306 – State Coverage Insurance
8.306.12 Member Grievance Resolution
8.306.14 Reporting Requirements
8.306.15 Services for SCI Members with Special Health Care Needs
8.306.16 Member Transition of Care
8.306.9 Coordination of Benefits
Archived Program Rules – Chapter 307 – Coordinated Long-Term Services
8.307.12 Member Grievance Resolution
8.307.14 Reporting Requirements
8.307.15 Services for Members with Special Health Care Needs
8.307.16 Client Transition of Care
8.307.18 CoLTS 1915 (c) Home and Community- Based Services Waiver
8.307.9 Coordination of Services
Archived Program Rules – Chapter 308 Managed Care Program
8.308.11 Transition of Care 1/1/19 – 4/4/22
8.308.20 Reimbursement 1/1/14 – 4/4/22
8.308.10 Care Coordination 5/1/18 – 12/31/18
8.308.12 Community Benefit 3/1/17 – 12/13/18
8.308.12 Community Benefits 8/1/14 – 2/28/17
8.308.6 Eligibility 1/1/19 – 8/8/21
8.308.6 Eligibility 5/1/18 – 12/31/18
8.308.7 Eligibility 1/1/19 – 8/9/21
8.308.7 Enrollment and Disenrollment 5/1/18 – 12/31/18
8.308.9 Benefit Package 1/1/19 to 4/4/22
8.308.9 Benefit Package 5/1/18 – 12/31/18
Archived Program Rules – Chapter 310 – Health Care Professional Services
8.310.3 Professional Providers, Services and Reimbursement 1/1/14 – 12/31/22
8.310.10 Health Home Services 4/1/16 – 4/29/18
8.310.10 MAD 718.1 Midwife Services
8.310.15 Intensive Out Patient Services
8.310.2 Medical Services Providers
8.310.3 Rural Health Clinic Services
8.310.8 Behavioral Health Professional Services
8.310.2 General Benefit Description 8/10/21 to 4/4/22
8.310.2 General Benefit Description 1/1/14 – 8/9/21
Archived Program Rules – Chapter 311 – Hospital Services
8.311.3 Methods and Standards for Establishing Payment 1/1/19 to 8/31/21
8.311.3 Methods and Standards for Establishing Payment – IHS 1/1/18 – 12/31/18
8.311.3 Methods and Standards for Establishing Payment – IHS 6/1/12 – 5/31/16
8.311.3 Methods and Standards for Establishing Payment – IHS 6/1/16 – 12/26/17
8.311.4 MAD 722 Outpatient Psychiatric Services and Partial Hospitalization
8.311.3 Methods and Standards for Establishing Payment 1/1/19 to 8/31/21
Archived Program Rules – Chapter 312 Long-Term Care Services – Nursing Services
8.312.3 Cost-Related Reimbursement of Nursing Facilities
8.314.5 Developmental Disabilities Home and Community Based Waiver
8.314.3 Medically Fragile Home and Community – Based Services Waiver 3/1/18 – 6/30/19
8.314.3 Medically Fragile Home and Community-Based Services Waiver 12/1/10 – 2/28/18
8.314.5 Developmental Disabilities Home and Community-Based Services Waiver 03/01/16-11/30/18
8.314.5 Developmental Disabilities Home and Community-Based Services Waiver 2/1/15-2/29/16
8.314.5 Developmental Disabilities Home and Community-Based Waiver
8.314.6 Mi Via Home and Community-Based Services Waiver
8.314.6 Mi Via Home and Community-Based Services Waiver 2/14/14 – 2/29/16
8.314.6 Mi Via Home and Community-Based Services Waiver 3/1/16 – 10/31/18
Archived Program Rules – Chapter 315 – Other Specialized Services and Providers
8.315.3 Psychosocial Rehabilitation Services
8.315.4 Personal Care Option (PCO) Services
8.315.5 Assertive Community Treatment (ACT) Services
8.315.6 Comprehensive Community Support Services
Archived Program Rules – Chapter 320 – Early and Periodic Screening, Diagnosis and Treatment
8.320.2 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services 2/1/20 to 12/31/20
8.320.2 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services 1/1/2014 to 1/31/2020
8.320.3 Tot-To-Teen Health Check
8.320.4 Special Rehabilitation Services
8.320.6 School Based Services for Recipients Under 21 Years of Age
8.320.6 School Based Services for Recipients Under 21 Years of Age
Archived Program Rules – Chapter 321 – Specialized Behavioral Health Services
8.321.2 Specialized Behavioral Health Provider Enrollment and Reimbursement 8/10/21 to 2/28/23
8.321.2 Inpatient Psychiatric Care in Freestanding Psychiatric Hospital
8.321.2 Specialized Behavioral Health Provider Enrollment and Reimbursement
8.321.3 Accredited Residential Treatment Center Services
8.321.4 Non-Accredited Residential Treatment Centers and Group Homes
8.321.5 Outpatient and Partial Hospitalization Services in Freestanding Psychiatric Hospitals
Archived Program Rules – Chapter 322 – Enhanced EPSDT: Community Mental Health Services
8.322.3 MAD 745.2 Behavior Management Skills Development Services
8.322.4 MAD 745.3 Day Treatment
8.322.5 Treatment Foster Care II
8.322.6 Multi-Systematic Therapy Services
Archived Program Rules – Chapter 323 – Enhanced EPSDT: Out-Patient Providers
8.323.2 EPSDT Personal Care Services
8.323.3 MAD 746.6 Licensed Alcohol and Drug Abuse Counselors
8.323.4 EPSDT Private Duty Nursing Services
8.323.5 EPSDT Rehabilitation Services
Archived Program Rules – Chapter 324 – Adjunct Services
8.324.3 Diagnostic Imaging an Therapeutic Radiology Services
8.324.5 Durable Medical Equipment and Medical Supplies
8.324.6 Hearing Aids and Related Evaluations
8.324.7 Transportation Services
8.324.8 Prosthetics and Orthotic
Archived Program Rules – Chapter 325 – Specialty Services
8.325.10 Emergency Medical Services for Aliens
8.325.11 Medication Assisted Treatment for Opioid Addiction
8.325.3 MAD 762 Reproductive Health Services
8.325.6 Experimental or Investigational Procedures, Technologies or Non-Drug Therapies
8.325.7 Pregnancy Termination Procedures
8.325.8 Rehabilitation Service Providers
Archived Program Rules – Chapter 326 – Case Management Services
8.326.3 Case Management for Pregnant Women and their Infants 3/1/12 to 4/4/22
Archived Program Rules – Chapter 351 – Sanctions or Remedies
8.351.2 Sanctions and Remedies
Archived Program Rules – Chapter 352 – Recipient Hearing Policies
Archived Program Rules – Chapter 353 – Provider Hearing Policies
Archived Program Rules – Chapter 354 – Preadmission Screening and Annual Review (PASSR) and Patient Status Policies
8.354.2 PASRR and Patient Status Hearing Policies
Archived Utilization Review Policies
8.312.2 UR Long Term Care Utilization Review for Nursing Facilities