Section 9. General Provider Instruction

A. Health care to New Mexico (NM) eligible recipients is furnished by a variety of providers and provider groups. The reimbursement for these services is administered by the HCA medical assistance division (MAD). Upon approval of a NM MAD provider participation agreement (PPA) a licensed practitioner, a facility or other providers of services that meet applicable requirements are eligible to be reimbursed for furnishing MAD covered services to an eligible recipient. A provider must be approved before submitting a claim for payment to the MAD claims processing contractors. Information necessary to participate in health care programs administered by HCA or its authorized agents, including NM administrative code (NMAC) program rules, program policy manuals, billing instructions, supplements, utilization review (UR) instructions, and other pertinent materials is available on the HCA website, on other program specific websites or in hard copy format. When approved, a provider receives instructions on how to access these documents. It is the provider’s responsibility to access these instructions, to understand the information provided and to comply with the requirements. The provider must contact HCA or its authorized agents to obtain answers to questions related to the material or not covered by the material. To be eligible for reimbursement, providers and practitioners must adhere to the provisions of their MAD PPA and all applicable statutes, regulations, rules, and executive orders. MAD or its selected claims processing contractor issues payment to a provider using the electronic funds transfer (EFT) only. Providers must supply necessary information as outlined in the PPA for payment to be made. B. Services must be provided within the licensure for each facility and scope of practice for each provider and supervising or rendering practitioner. Services must be in compliance with the statutes, rules and regulations of the applicable practice act rovider using the electronic funds transfer (EFT) only. Providers must supply necessary information as outlined in the PPA for payment to be made. B. Services must be provided within the licensure for each facility and scope of practice for each provider and supervising or rendering practitioner. Services must be in compliance with the statutes, rules and regulations of the applicable practice act. Providers must be eligible for reimbursement as described in 8.310.2 NMAC and 8.310.3 NMAC. 8.321.2 NMAC 2 C. The following independent providers with active licenses are eligible to be reimbursed directly for providing MAD covered behavioral health professional services unless otherwise restricted or limited by NMAC rules: (1) a physician licensed by the board of medical examiners or board of osteopathy who is board eligible, or board certified in psychiatry, to include the groups they form; (2) a psychologist (Ph.D., Psy.D. or Ed.D.) licensed as a clinical psychologist by the NM regulation and licensing department’s (RLD) board of psychologist examiners, to include the groups they form; (3) a licensed independent social worker (LISW) or a licensed clinical social worker (LCSW) licensed by RLD’s board of social work examiners, to include the groups they form; (4) a licensed professional clinical counselor (LPCC) licensed by RLD’s counseling and therapy practice board, to include the groups they form; (5) a licensed marriage and family therapist (LMFT) licensed by RLD’s counseling and therapy practice board, to include the groups they form; (6) a licensed alcohol and drug abuse counselor (LADAC) licensed by RLD’s counseling and therapy practice board or a certified alcohol and drug abuse counselor (CADC) certified by the NM credentialing board for behavioral health professionals (CBBHP). Independent practice is for alcohol and substance use diagnoses only y RLD’s counseling and therapy practice board, to include the groups they form; (6) a licensed alcohol and drug abuse counselor (LADAC) licensed by RLD’s counseling and therapy practice board or a certified alcohol and drug abuse counselor (CADC) certified by the NM credentialing board for behavioral health professionals (CBBHP). Independent practice is for alcohol and substance use diagnoses only. The LADAC or CADC may provide therapeutic services that may include treatment of clients with co-occurring disorders or dual diagnoses in an integrated behavioral health setting in which an interdisciplinary team has developed an interdisciplinary treatment plan that is co-authorized by an independently licensed counselor or therapist. The treatment of a mental health disorder must be supervised by an independently licensed counselor or therapist; or (7) a clinical nurse specialist (CNS) or a certified nurse practitioner (CNP) licensed by the NM board of nursing and certified in psychiatric nursing by a national nursing organization, to include the groups they form, who can furnish services to adults or children as their certification permits; or (8) a licensed professional art therapist (LPAT) licensed by RLD’s counseling and therapy practice board, and certified for independent practice by the art therapy credentials board (ATCB); (9) an occupational therapist licensed by the RLD board of examiners for occupational therapy; who is facilitating occupational performance and managing an individual’s mental health functioning and performance in accordance with the NM occupational therapy act; or (10) an out-of-state provider rendering a service from out-of-state must meet their state’s licensing and certification requirements which are acceptable when deemed by MAD to be substantially equivalent to the license. D herapy; who is facilitating occupational performance and managing an individual’s mental health functioning and performance in accordance with the NM occupational therapy act; or (10) an out-of-state provider rendering a service from out-of-state must meet their state’s licensing and certification requirements which are acceptable when deemed by MAD to be substantially equivalent to the license. D. The following agencies are eligible to be reimbursed for providing behavioral health professional services when all conditions for providing services are met: (1) a community mental health center (CMHC); (2) a federally qualified health center (FQHC); (3) an Indian health service (IHS) hospital, clinic or FQHC; (4) a PL 93-638 tribally operated hospital, clinic or FQHC; (5) to the extent not covered by Paragraphs (3) and (4) of Subsection D of 8.321.2.9 NMAC above, an “Indian health care provider (IHCP)” defined in 42 code of federal regulations §438.14(a). (6) a children, youth and families department (CYFD) facility; (7) a hospital and its outpatient facility; (8) a core service agency (CSA); (9) a CareLink NM health home (CLNM HH); (10) a crisis triage center licensed by the department of health (DOH); (11) a behavioral health agency (BHA); (12) an opioid treatment program in a methadone clinic; (13) a political subdivision of the state of NM; (14) a crisis services community provider as a BHA; and (15) a school based health center. E patient facility; (8) a core service agency (CSA); (9) a CareLink NM health home (CLNM HH); (10) a crisis triage center licensed by the department of health (DOH); (11) a behavioral health agency (BHA); (12) an opioid treatment program in a methadone clinic; (13) a political subdivision of the state of NM; (14) a crisis services community provider as a BHA; and (15) a school based health center. E. A behavioral health service rendered by a licensed practitioner listed in Paragraph (2) of Subsection E of 8.321.2.9 NMAC whose scope of licensure does not allow them to practice independently or a non- licensed practitioner listed in Paragraph (3) of Subsection E of 8.321.2.9 NMAC is covered to the same extent as if rendered by a practitioner licensed for independent practice, when the supervisory requirements are met consistent with the practitioner’s licensing board within their scope of practice and the service is provided through and billed by one of the provider agencies listed in numbers Paragraphs (1) through (15) of Subsection D of 8.321.2.9 NMAC. 8.321.2 NMAC 3 All services must be delivered according to the medicaid regulation and current version of the BH policy and billing manual. If the service is an evaluation, assessment, or therapy service rendere d by the practitioner and supervised by an independently licensed practitioner, the independently licensed practitioner’s practice board must specifically allow them to supervise the non-independent practitioner. (1) Specialized behavioral health services, other than evaluation, assessment, or therapy services, may have specific rendering practitioner requirements which are detailed in each behavioral health services section of 8.321.2.9 NMAC ependently licensed practitioner, the independently licensed practitioner’s practice board must specifically allow them to supervise the non-independent practitioner. (1) Specialized behavioral health services, other than evaluation, assessment, or therapy services, may have specific rendering practitioner requirements which are detailed in each behavioral health services section of 8.321.2.9 NMAC. (2) The non-independently licensed rendering practitioner with an active license must be one of the following: (a) a licensed master of social work (LMSW) licensed by RLD’s board of social work examiners; (b) a licensed mental health counselor (LMHC) licensed by RLD’s counseling and therapy practice board; (c) a licensed professional mental health counselor (LPC) licensed by RLD’s examiner board; (d) a licensed associate marriage and family therapist (LAMFT) licensed by RLD’s examiner board; (e) a psychologist associate licensed by the RLD’s psychologist examiners board; (f) a licensed substance abuse associate (LSAA) licensed by RLD’s counseling and therapy practice board will be eligible for reimbursement aligned with each tier level of designated scope of practice determined by the board; (g) a registered nurse (RN) licensed by the NM board of nursing under the supervision of a certified nurse practitioner, clinical nurse specialist or physician; or (h) a licensed physician assistant certified by the state of NM if supervised by a behavioral health physician or DO licensed by RLD’s examiner board aligned with each tier level of designated scope of practice determined by the board; (g) a registered nurse (RN) licensed by the NM board of nursing under the supervision of a certified nurse practitioner, clinical nurse specialist or physician; or (h) a licensed physician assistant certified by the state of NM if supervised by a behavioral health physician or DO licensed by RLD’s examiner board. (3) Non-licensed practitioners working under RLD board approved supervisor, must be one of the following: (a) a master’s level behavioral health intern; (b) a psychology intern including psychology practicum students, pre-doctoral internship; (c) a pre-licensure psychology post doctorate student; (d) a certified peer support worker; (e) a certified family peer support worker; (f) a certified youth peer support specialist; (g) a community support worker (CSW); (h) a community health worker (CHW); (i) a tribal community health representative (TCHR); or (j) a provisional or temporarily licensed master’s level behavioral health professional. (4) The rendering practitioner must be enrolled as a MAD provider. F. An eligible recipient under 21 years of age may be identified through a tot to teen health check, self-referral, referral from an agency (such as a public school, childcare provider, or other practitioner) when they are experiencing behavioral health concerns. G. Either as a separate service or a component of a treatment plan or a bundled service, the following services are not MAD covered benefits: (1) hypnotherapy; (2) biofeedback; (3) conditions that do not meet the standard of medical necessity as defined in 8.302.1 NMAC; (4) educational or vocational services related to traditional academic subjects or vocational training; (5) experimental or investigational procedures, technologies or non-drug therapies and related services; (6) activity therapy, group activities and other services which are primarily recreational or diversional in nature; (7) electroconvulsive therapy; 8.321.2 NMAC 4 (8) services provided by a ; (4) educational or vocational services related to traditional academic subjects or vocational training; (5) experimental or investigational procedures, technologies or non-drug therapies and related services; (6) activity therapy, group activities and other services which are primarily recreational or diversional in nature; (7) electroconvulsive therapy; 8.321.2 NMAC 4 (8) services provided by a behavioral health practitioner who is not in compliance with the statutes, regulations, rules or renders services outside their scope of practice; (9) treatment of intellectual disabilities alone; (10) services not considered medically necessary for the condition of the eligible recipient; (11) services for which prior authorization is required but was not obtained; and (12) milieu therapy. H. All behavioral health services must meet the definition of medical necessity found in 8.302.1 NMAC. Performance of a MAD covered behavioral health service cannot be delegated to a provider or practitioner not licensed for independent practice except as specified within this rule, within their practice board’s scope and practice and in accordance with applicable federal, state, and local statutes, laws, and rules. When a service is performed by a supervised practitioner, the supervision of the service cannot be billed separately or additionally. Other than agencies as allowed in Subsections D and E of 8.321.2.9 NMAC, a behavioral health provider cannot, themselves, as a rendering provider, bill for a service for which they were providing supervision, and the service was in part or wholly performed by a different individual. Behavioral health services are reimbursed as follows, except when otherwise described within a particular specialized service’s reimbursement section. (1) Once enrolled, a provider receives instructions on how to access documentation, billing, and claims processing information vice for which they were providing supervision, and the service was in part or wholly performed by a different individual. Behavioral health services are reimbursed as follows, except when otherwise described within a particular specialized service’s reimbursement section. (1) Once enrolled, a provider receives instructions on how to access documentation, billing, and claims processing information. Reimbursement is made to a provider for covered services at the lesser of the following: (a) the MAD fee schedule for the specific service or procedure; or (b) the provider’s billed charge. The provider’s billed charge must be its usual and customary charge for services (“usual and customary charge” refers to the amount that the individual provider charges the general public in the majority of cases for a specific procedure or service). (2) Reimbursement is made for an Indian health service (IHS) agency, a PL 93-638 tribal health facility, a federally qualified health center (FQHC), any other “Indian health care provider (IHCP)” as defined in 42 Code of Federal Regulations §438.14(a), rural health clinic, or hospital-based rural health clinic by following its federal guidelines and special provisions as detailed in 8.310.4 and 8.310.12 NMAC. I. All behavioral health services are subject to utilization review for medical necessity and program compliance. Reviews can be performed before services are furnished, after service is furnished but before a payment is made, or after the payment is made; see 8.310.2 NMAC. The provider must contact HCA or its authorized agents to request UR instructions. It is the provider’s and practitioner’s responsibility to access these instructions or ask for paper copies to be provided, to understand the information provided, to comply with the requirements, and to obtain answers to questions not covered by these materials made, or after the payment is made; see 8.310.2 NMAC. The provider must contact HCA or its authorized agents to request UR instructions. It is the provider’s and practitioner’s responsibility to access these instructions or ask for paper copies to be provided, to understand the information provided, to comply with the requirements, and to obtain answers to questions not covered by these materials. When services are billed to and paid by a coordinated services contractor authorized by HCA, the provider must follow that contractor’s instructions for authorization of services. A specialized behavioral health service may have additional prior authorization requirements listed in that service’s prior authorization subsection. All prior authorization procedures must follow federal parity law. J. For an eligible recipient to access behavioral health services, a practitioner must complete a diagnostic evaluation, progress and treatment notes and teaming notes, if indicated. Exceptions to this whereby a treatment or set of treatments may be performed before a diagnostic evaluation has been done, utilizing a provisional diagnosis based on screening results are outlined in 8.321.2.15, 8.321.2.19 and 8.321.2.35 NMAC and in the BH policy and billing manual. For a limited set of treatments, (i.e. four or less), no treatment plan is required. All documentation must be signed, dated and placed in the eligible recipient’s file. All documentation must be made available for review by HCA or its designees in the eligible recipient’s file (see the BH policy and billing manual for specific instructions). K. For recipients meeting the NM state definition of serious mental illness (SMI) for adults or severe emotional disturbances (SED) for recipients under 18 years of age or a substance use disorder (SUD) for any age, a comprehensive assessment or diagnostic evaluation and treatment plan must be completed (see the BH policy and billing manual for specific instructions) al for specific instructions). K. For recipients meeting the NM state definition of serious mental illness (SMI) for adults or severe emotional disturbances (SED) for recipients under 18 years of age or a substance use disorder (SUD) for any age, a comprehensive assessment or diagnostic evaluation and treatment plan must be completed (see the BH policy and billing manual for specific instructions). (1) A comprehensive assessment and treatment plan can only be billed by the agencies listed in Subsection D of 8.321.2.9 NMAC. (2) Behavioral health treatment plans can be developed by individuals employed by the agency who have Health Insurance Portability and Accountability Act (HIPAA) training, are working within their scope of practice, and are working under the supervision of the rendering provider who must be a RLD board approved supervisor. 8.321.2 NMAC 5 (3) A comprehensive assessment and treatment plan cannot be billed if care coordination is being billed through bundled service packages such as case rates, value-based purchasing agreements, high fidelity wraparound or CareLink NM (CLNM) health homes. L. MAD covers treatment plans, and updates, created with interdisciplinary teams for out-patient recipients meeting the NM state definition for SMI, SED, or SUD in which multiple provider disciplines are engaged to address co-occurring conditions, or other social determinants of health. (1) Coverage, purpose and frequency of interdisciplinary team meetings: (a) provides the central learning, decision-making, and service integrating elements that weave practice functions together into a coherent effort for helping a recipient meet needs and achieve life goals; and (b) covered team meetings resulting in treatment plan changes or updates are limited to an annual review, when recipient conditions change, or at critical decision points in the recipient’s progress to recovery. (2) The team consists of: (a) a lead agency, which must be one of the agencies listed in Subsection D of 8.321.2.9 NMAC ffort for helping a recipient meet needs and achieve life goals; and (b) covered team meetings resulting in treatment plan changes or updates are limited to an annual review, when recipient conditions change, or at critical decision points in the recipient’s progress to recovery. (2) The team consists of: (a) a lead agency, which must be one of the agencies listed in Subsection D of 8.321.2.9 NMAC. This agency has a designated and qualified team lead who prepares team members, convenes and organizes meetings, facilitates the team decision-making process, and follows up on commitments made; (b) a participating provider that is a MAD enrolled provider that is either already treating the recipient or is new to the case and has the expertise pertinent to the needs of the individual. This provider may practice within the same agency but in a differing discipline, or outside of the lead agency; (c) other participating providers not enrolled with MAD, other subject matter experts, and relevant family and natural supports may be part of the team, but are not reimbursed through MAD; and (d) the recipient, who is the subject of this treatment plan update, must be a participating member of every teaming meeting. (3) Reimbursement: (a) only the team lead and two other MAD enrolled participating providers or agencies may bill for the interdisciplinary team update. When more than three MAD enrolled providers are engaged within the session, the team decides who will bill based on the level of effort or change within their own discipline. (b) when the team lead and only one other provider meet to update the treatment plan, the definition of teaming is not met and the treatment plan update may not be billed using the interdisciplinary teaming codes team update. When more than three MAD enrolled providers are engaged within the session, the team decides who will bill based on the level of effort or change within their own discipline. (b) when the team lead and only one other provider meet to update the treatment plan, the definition of teaming is not met and the treatment plan update may not be billed using the interdisciplinary teaming codes. (c) the six elements of teaming may be performed by using a variety of media (with the person’s knowledge and consent) e.g., texting members to update them on an emergent event; using email communications to ask or answer questions; sharing assessments, plans and reports; conducting conference calls via telephone; using telehealth platforms conferences; and, conducting face-to-face meetings with the person present when key decisions are made. Only conducting the final face-to-face meeting with the recipient present when key decisions are made that result in the updates to the treatment plan, is a billable event. (d) when updates to the treatment plan, that was developed within the comprehensive assessment, are developed using the interdisciplinary teaming model described in the BH policy and billing manual, service codes specific for interdisciplinary teaming may be billed. If the teaming model is not used, only the standard codes for updating the treatment plan can be billed. An update to the treatment plan using a teaming method approach and an update to the treatment plan not using the teaming method approach, cannot both be billed. (e) billing instructions are found in the BH policy and billing manual. M. For recipients with behavioral health diagnoses and other co-occurring conditions, or other social determinants of health meeting medical necessity, and for whom multiple provider disciplines are engaged, MAD covers treatment plan development and one subsequent update per year for an interdisciplinary team t both be billed. (e) billing instructions are found in the BH policy and billing manual. M. For recipients with behavioral health diagnoses and other co-occurring conditions, or other social determinants of health meeting medical necessity, and for whom multiple provider disciplines are engaged, MAD covers treatment plan development and one subsequent update per year for an interdisciplinary team. (1) The team consists of: (a) a lead MAD enrolled provider that has primary responsibility for coordinating the interdisciplinary team, convenes and organizes meetings, facilitates the team decision-making process, and follows up on commitments made; (b) a participating MAD enrolled provider from a different discipline; (c) other participating providers not enrolled with MAD, other subject matter experts, and relevant family and natural supports may be part of the team, but are not reimbursed through MAD; and (d) the recipient, who is the subject of this treatment plan development and update, must be a participating member of each team meeting. 8.321.2 NMAC 6 (2) Reimbursement: (a) only the team lead and one other MAD enrolled participating provider may bill for a single session. When more than two MAD enrolled providers are engaged with the session, the team decides who will bill based on the level of effort or change within their own discipline; (b) this treatment plan development and subsequent update to the original plan can only be billed twice within one year; and (c) billing instructions are found in the BH policy and billing manual. N. All specialized behavioral health services should be delivered in the least restrictive setting. Least restrictive settings will differ between services and facilities and are generally defined as a physical setting which places the least restraint on the client’s freedom of movement and opportunity for independence and enables an individual to function with as much choice and self-direction as safely appropriate behavioral health services should be delivered in the least restrictive setting. Least restrictive settings will differ between services and facilities and are generally defined as a physical setting which places the least restraint on the client’s freedom of movement and opportunity for independence and enables an individual to function with as much choice and self-direction as safely appropriate. In addition, access to or receipt of one service may not be contingent on requiring an individual to obtain or utilize any other service; for example, a housing service may not require a treatment component, nor may an outpatient treatment service require participation in housing. Multiple services may be encouraged, under appropriate circumstances, but may not be required. O. Site visits must be conducted for specialized behavioral health services. Site visit requirements are outlined in the BH policy and billing manual. [8.321.2.9 NMAC - Rp, 8.321.2.9 NMAC, 12/10/2024] 8.321.2.10 ADULT ACCREDITED RESIDENTIAL TREATMENT CENTER (AARTC) FOR ADULTS WITH SUBSTANCE USE DISORDERS: To help an eligible recipient 18 years of age and older, who has been diagnosed as having a SUD, and the need for AARTC has been identified in the eligible recipient’s diagnostic evaluation as meeting criteria of the American society of addiction medicine (ASAM) level of care three for whom a less restrictive setting is not appropriate, MAD pays for services furnished to them by an AARTC accredited by the joint commission (JC), the commission on accreditation of rehabilitation facilities (CARF) or the council on accreditation (COA). A. Eligible facilities: (1) To be eligible to be reimbursed for providing AARTC services to an eligible recipient, an AARTC facility: (a) must be accredited by JC, COA, or CARF as an adult (18 and older) residential treatment facility; (b) must be certified through an application process with the behavioral health services division (BHSD) which includes site visits council on accreditation (COA). A. Eligible facilities: (1) To be eligible to be reimbursed for providing AARTC services to an eligible recipient, an AARTC facility: (a) must be accredited by JC, COA, or CARF as an adult (18 and older) residential treatment facility; (b) must be certified through an application process with the behavioral health services division (BHSD) which includes site visits. Site visit requirements are outlined in the BH policy and billing manual; (c) must have written policies and procedures specifying ASAM level of care three criteria as the basis for accepting eligible recipients into the sub-level treatment program; (d) must meet ASAM treatment service requirements for the ASAM level of care three recipients it admits into each sub-level of care; (e) must provide medication assisted treatment (MAT) for opioid use disorder (OUD), as indicated. See 8.321.2.28 NMAC for MAT requirements. An AARTC may coordinate with another agency for provision of MAT services when they are not provided by the AARTC; an AARTC may not exclude recipients from receiving AARTC services on the basis of receiving MAT services; (f) all licensed practitioners shall be trained in ASAM principles and levels of care. The ASAM training must comprehensively cover the expected treatment expectations of the ASAM level 3 sub- level treatment programs; (g) prior to the initial hire and every three years thereafter employees must pass a nationwide caregiver criminal history screening pursuant to Section 29-17-2 et seq. NMSA 1978 and 7.1.9 NMAC and an abuse registry screen pursuant to Section 27-7a-1 et seq s of care. The ASAM training must comprehensively cover the expected treatment expectations of the ASAM level 3 sub- level treatment programs; (g) prior to the initial hire and every three years thereafter employees must pass a nationwide caregiver criminal history screening pursuant to Section 29-17-2 et seq. NMSA 1978 and 7.1.9 NMAC and an abuse registry screen pursuant to Section 27-7a-1 et seq. NMSA 1978 and 8.11.6 NMAC; additionally employees must pass the employee abuse registry (EAR) pursuant to 7.1.12 NMAC, certified nurse aide registry pursuant to 16- 12.20 NMAC, office of inspector exclusion list pursuant to section 1128B(f) of the Social Security Act; and the national sex offender registry pursuant to 6201 as federal authority for active programs; (h) must maintain appropriate drug permit required, issued by the state board of pharmacy, as applicable; (i) must maintain appropriate food service permit required, issued by the New Mexico environmental department (NMED), as applicable; and 8.321.2 NMAC 7 (j) must allow individuals the opportunity to notify their family that they have been admitted to the facility and shall not admit an individual for residential treatment without obtaining or providing evidence that the facility has attempted to obtain contact information for a family member of the patient. (2) An out-of-state or MAD enrolled border AARTC must have JC, CARF or COA accreditation, use ASAM level three criteria for accepting recipients, and be licensed in its own state as an AARTC residential treatment facility. B. Coverage criteria: (1) Treatment must be provided under the direction of an independently licensed clinician or practitioner as defined by ASAM criteria level three for the sub-level of treatment being rendered. (2) Treatment shall be based on the eligible recipient’s individualized treatment plan rendered by the AARTC facility’s practitioners, within the scope and practice of their professions as defined by state law, rule or regulation provided under the direction of an independently licensed clinician or practitioner as defined by ASAM criteria level three for the sub-level of treatment being rendered. (2) Treatment shall be based on the eligible recipient’s individualized treatment plan rendered by the AARTC facility’s practitioners, within the scope and practice of their professions as defined by state law, rule or regulation. See Subsection B of 8.321.2.9 NMAC for general behavioral health professional requirements. (3) The following services shall be performed by the AARTC agency to receive reimbursement from MAD: (a) diagnostic evaluation, necessary psychological testing, and development of the eligible recipient’s treatment plan, while ensuring that evaluations already performed are not repeated; (b) provision of regularly scheduled counseling and therapy sessions in an individual, family or group setting following the eligible recipient’s treatment plan, and according to ASAM guidelines for level three, residential care, and the specific sub-level of care for which that client meets admission criteria; (c) facilitation of age-appropriate life skills development; (d) assistance to the eligible recipient in their self-administration of medication in compliance with state statute, regulation and rules; (e) maintain appropriate staff available on a 24-hour basis to respond to crisis situations, determine the severity of the situation, stabilize the eligible recipient, make referrals as necessary, and provide follow-up to the eligible recipient; and (f) consultation with other professionals or allied caregivers regarding the needs of the eligible recipient, as applicable. (4) Admission and treatment criteria based on the sub-levels of ASAM level three criteria must be met. Length of stay is determined by medical necessity. The differing sub-levels of ASAM level three are based on the intensity of clinical services, particularly as demonstrated by the degree of involvement of medical and nursing professionals rding the needs of the eligible recipient, as applicable. (4) Admission and treatment criteria based on the sub-levels of ASAM level three criteria must be met. Length of stay is determined by medical necessity. The differing sub-levels of ASAM level three are based on the intensity of clinical services, particularly as demonstrated by the degree of involvement of medical and nursing professionals. The defining characteristic of level three ASAM criteria is that they serve recipients who need safe and stable living environments to develop their recovery skills. They are transferred to lower levels of care when they have established sufficient skills to safely continue treatment without the immediate risk of relapse, continued use, or other continued problems, and are no longer in imminent danger of harm to themselves or others. (5) Levels of care without withdrawal management: (a) clinically managed low-intensity residential services as specified in ASAM level of care 3.1 are covered for recipients whose condition meets the criteria for ASAM 3.1: (i) is often a step down from a higher level of care and prepares the recipient for transition to the community and outpatient services; and (ii) requires a minimum of five hours per week of recovery skills development. (b) clinically managed population-specific high-intensity residential services as specified in ASAM levels of care 3.3 and 3.5 are covered for recipients whose condition meets the criteria of ASAM level 3.3 or 3.5. (i) level 3.3 meets the needs of recipients with cognitive difficulties needing more specialized individualized services. Cognitive impairments can be due to aging, traumatic brain injury, acute but lasting injury, or illness. (ii) level 3.5 offers a higher intensity of service not requiring medical monitoring are covered for recipients whose condition meets the criteria of ASAM level 3.3 or 3.5. (i) level 3.3 meets the needs of recipients with cognitive difficulties needing more specialized individualized services. Cognitive impairments can be due to aging, traumatic brain injury, acute but lasting injury, or illness. (ii) level 3.5 offers a higher intensity of service not requiring medical monitoring. (c) medically monitored intensive inpatient services as specified in ASAM level of care 3.7 are covered for recipients whose condition meets the criteria for ASAM level 3.7: (i) 3.7 level is an organized service delivered by medical and nursing professionals which provides 24-hour evaluation and monitoring services under the direction of a physician or clinical nurse practitioner who is available by phone 24-hours a day; 8.321.2 NMAC 8 (ii) nursing staff is on-site 24-hours a day; (iii) other interdisciplinary staff of trained clinicians may include counselors, social workers, emergency medical technicians with documentation of three hours of annual training in SUD, and psychologists available to assess and treat the recipient and to obtain and interpret information regarding recipient needs. (6) Withdrawal management (WM) levels of care: (a) clinically managed residential withdrawal management services as specified in ASAM level of care 3.2WM for recipients whose condition meets the criteria for ASAM 3.2WM: (i) managed by behavioral health professionals, with protocols in place should a patient’s condition deteriorate and appear to need medical or nursing interventions; (ii) ability to arrange for appropriate laboratory and toxicology tests; (iii) a range of cognitive, behavioral, medical, mental health and other therapies administered on an individual or group basis to enhance the recipient’s understanding of SUD, the completion of the withdrawal management process, and referral to an appropriate level of care for continuing treatment; (iv) the recipient remains in a level 3.2WM program until withdrawal signs and sym oxicology tests; (iii) a range of cognitive, behavioral, medical, mental health and other therapies administered on an individual or group basis to enhance the recipient’s understanding of SUD, the completion of the withdrawal management process, and referral to an appropriate level of care for continuing treatment; (iv) the recipient remains in a level 3.2WM program until withdrawal signs and symptoms are sufficiently resolved that the recipient can be safely managed at a less intensive level of care; or the recipient’s signs and symptoms of withdrawal have failed to respond to treatment and have intensified such that transfer to a more intensive level of withdrawal management services is indicated; and (v) 3.2WM’s length of stay is typically 3 - 5 days, after which transfer to another level of care is indicated. (b) medically monitored residential withdrawal management services as specified in ASAM level of care 3.7WM for recipients whose condition meets the criteria for ASAM 3.7WM: (i) services are provided by an interdisciplinary staff of nurses, counselors, social workers, addiction specialists, peer support workers, emergency medical technicians with documentation of three hours of annual training in SUD, or other health and technical personnel under the direction of a licensed physician; (ii) monitored by medical or nursing professionals, with 24-hour nursing care and physician visits as needed, with protocols in place should a patient’s condition deteriorate and appear to need intensive inpatient withdrawal management interventions; (iii) ability to arrange for appropriate laboratory and toxicology tests; (iv) a range of cognitive, behavioral, medical, mental health and other therapies administered on an individual or group basis to enhance the recipient’s understanding of SUD, the completion of the withdrawal management process, and referral to an appropriate level of care for continuing treatment; and (v) the recipient remains in a level 3.7WM program until withdrawal signs and symptoms are sufficiently range of cognitive, behavioral, medical, mental health and other therapies administered on an individual or group basis to enhance the recipient’s understanding of SUD, the completion of the withdrawal management process, and referral to an appropriate level of care for continuing treatment; and (v) the recipient remains in a level 3.7WM program until withdrawal signs and symptoms are sufficiently resolved that they can be safely managed at a less intensive level of care; or the recipient’s signs and symptoms of withdrawal have failed to respond to treatment and have intensified such that transfer to a more intensive level of withdrawal management service is indicated; (vi) 3.7WM typically last for no more than seven days. C. Covered services: AARTCs treating all recipients meeting ASAM level three criteria. MAD covers residential treatment services which are medically necessary for the diagnosis and treatment of an eligible recipient’s condition. A clinically managed facility must provide 24-hour care with trained staff. D. Non-covered services: AARTC services are subject to the limitations and coverage restrictions that exist for other MAD covered services. See Subsection G of 8.321.2.9 NMAC for general MAD behavioral health non-covered services or activities. MAD does not cover the following specific services billed in conjunction with AARTC services to an eligible recipient: (1) comprehensive community support services (CCSS), except when provided by a CCSS agency in discharge planning for the eligible recipient from the facility; (2) services for which prior approval was not requested and approved; (3) services furnished to ineligible individuals; (4) formal educational and vocational services which relate to traditional academic subjects or vocational training; and (5) activity therapy, group activities, and other services primarily recreational or diversional in nature. 8.321.2 NMAC 9 E gible recipient from the facility; (2) services for which prior approval was not requested and approved; (3) services furnished to ineligible individuals; (4) formal educational and vocational services which relate to traditional academic subjects or vocational training; and (5) activity therapy, group activities, and other services primarily recreational or diversional in nature. 8.321.2 NMAC 9 E. Treatment plan: The treatment plan must be developed by a team of professionals in consultation with the eligible recipient and in accordance with ASAM and accreditation standards. The interdisciplinary team must review the treatment plan at least every 15 days. F. Prior authorization: Prior authorization is not required for up to five days for eligible recipients meeting ASAM level three criteria to facilitate immediate admission and treatment to the appropriate level of care. Within that five day period, the provider must furnish notification of the admission and if the provider believes that continued care beyond the initial five days is medically necessary, prior authorization must be obtained from MAD or its designee. For out-of-state AARTCs prior authorization is required prior to admission. Services for which prior authorization was obtained remain subject to utilization review at any point in the payment process. All MAD services are subject to utilization review for medical necessity, inspection of care, and program compliance. Follow up auditing is done by the accrediting agency per their standards. G. Reimbursement: An AARTC agency must submit claims for reimbursement on the UB-04 form or its successor. See Subsection H of 8.321.2.9 NMAC for MAD general reimbursement requirements and see 8.302.2 NMAC. Once enrolled, the agency receives instructions on how to access documentation, billing, and claims processing information. (1) MAD reimbursement covers services considered routine in the residential setting nt: An AARTC agency must submit claims for reimbursement on the UB-04 form or its successor. See Subsection H of 8.321.2.9 NMAC for MAD general reimbursement requirements and see 8.302.2 NMAC. Once enrolled, the agency receives instructions on how to access documentation, billing, and claims processing information. (1) MAD reimbursement covers services considered routine in the residential setting. Routine services include, but are not limited to, counseling, therapy, activities of daily living, medical management, crisis intervention, professional consultation, transportation, rehabilitative services and administration. (2) Services which are not covered in routine services include other MAD services that an eligible recipient might require that are not furnished by the facility, such as pharmacy services, primary care visits, laboratory or radiology services. These services are billed directly by the applicable providers and are governed by the applicable sections of NMAC rules. (3) MAD does not cover room and board. (4) Detailed billing instructions can be accessed in the BH policy and billing manual. [8.321.2.10 NMAC - Rp, 8.321.2.10 NMAC, 12/10/2024] 8.321.2.11 ADULT ACCREDITED RESIDENTIAL TREATMENT CENTER (AARTC) FOR ADULTS WITH SERIOUS MENTAL HEALTH CONDITIONS: To help an eligible recipient 18 years of age and older, who has been diagnosed as having a serious mental health condition, and the need for AARTC has been identified in the eligible recipient’s diagnostic evaluation as meeting criteria of the level of care utilization system (LOCUS) for psychiatric and SUD services level of care five for whom a less restrictive setting is not appropriate. MAD pays for services furnished to them by an AARTC accredited by the joint commission (JC), the commission on accreditation of rehabilitation facilities (CARF) or the council on accreditation (COA). A diagnostic evaluation as meeting criteria of the level of care utilization system (LOCUS) for psychiatric and SUD services level of care five for whom a less restrictive setting is not appropriate. MAD pays for services furnished to them by an AARTC accredited by the joint commission (JC), the commission on accreditation of rehabilitation facilities (CARF) or the council on accreditation (COA). A. Eligible facilities: (1) To be eligible to receive reimbursement for providing AARTC services to an eligible recipient, an AARTC facility: (a) must be accredited by JC, COA, or CARF as an adult (18 and older) residential treatment facility; (b) must be certified through an application process with BHSD which includes site visits. Site visit requirements are outlined in the BH policy and billing manual; (c) must have written policies and procedures specifying utilization of the LOCUS evaluation parameters for assessment of service needs and ensuring that based on the dimensional rating scale, clients meet LOCUS level 5 criteria as the basis for accepting eligible recipients into the treatment program; (d) must meet LOCUS level five service definitions for the care environment, clinical services, support services, and crisis stabilization and prevention services; (e) must assess for and treat co-occurring SUDs; (f) must provide or refer eligible recipients for MAT for SUD, if appropriate; to include access to buprenorphine and methadone, if appropriate and desired by the recipient. Programs may not exclude recipients from receiving AARTC services on the basis of receiving or desiring to receive MAT services. (g) must train all clinicians or practitioners in the LOCUS for psychiatric and SUD services UDs; (f) must provide or refer eligible recipients for MAT for SUD, if appropriate; to include access to buprenorphine and methadone, if appropriate and desired by the recipient. Programs may not exclude recipients from receiving AARTC services on the basis of receiving or desiring to receive MAT services. (g) must train all clinicians or practitioners in the LOCUS for psychiatric and SUD services. The LOCUS training must be conducted by a LOCUS approved trainer and must be comprehensive in covering the evaluation parameters for assessment of service needs and level of care definitions for LOCUS level 5 services; (h) prior to the initial hire and every three years thereafter employees must pass a nationwide caregiver criminal history screening pursuant to Section 29-17-2 et seq. NMSA 1978 and 7.1.9 NMAC and an abuse registry screen pursuant to section 27-7a-1 et seq. NMSA 1978 and 8.11.6 NMAC; additionally 8.321.2 NMAC 10 employees must pass the employee abuse registry (EAR) pursuant to 7.1.12 NMAC, certified nurse aide registry pursuant to 16- 12.20 NMAC, office of inspector exclusion list pursuant to section 1128B(f) of the Social Security Act; and the national sex offender registry pursuant to 6201 as federal authority for active programs; (i) must maintain appropriate drug permit required, issued by the state board of pharmacy, as applicable; (j) must maintain appropriate food service permit required, issued by the NMED, as applicable; and (k) must allow individuals the opportunity to notify their family that they have been admitted to the facility and shall not admit an individual for residential treatment without obtaining or providing evidence that the facility has attempted to obtain contact information for a family member of the patient. (2) An out-of-state or MAD enrolled border AARTC must have JC, CARF or COA accreditation, use LOCUS level five criteria for accepting recipients, and be licensed in its own state as an AARTC residential treatment facility. B individual for residential treatment without obtaining or providing evidence that the facility has attempted to obtain contact information for a family member of the patient. (2) An out-of-state or MAD enrolled border AARTC must have JC, CARF or COA accreditation, use LOCUS level five criteria for accepting recipients, and be licensed in its own state as an AARTC residential treatment facility. B. Coverage criteria: (1) Treatment must be provided under the direction of an independently licensed clinician/practitioner and the program must have sufficient staffing to meet the LOCUS level five clinical capabilities description. (2) Treatment shall be based on the eligible recipient’s individualized treatment plan rendered by the AARTC facility’s practitioners, within the scope and practice of their professions as defined by state law, rule or regulation. See Subsection B of 8.321.2.9 NMAC for general behavioral health professional requirements. (3) The following services shall be performed by the AARTC agency to receive reimbursement from MAD: (a) diagnostic evaluation, necessary psychological testing, and development of the eligible recipient’s treatment plan, while ensuring that evaluations already performed are not repeated; (b) provision of regularly scheduled counseling and therapy sessions in an individual, family or group setting following the eligible recipient’s treatment plan, and according to LOCUS level five service descriptions the care environment, clinical services, support services, and crisis stabilization and prevention services; (c) facilitation of age-appropriate life skills development; (d) assistance to the eligible recipient in their self-administration of medication in compliance with state statute, regulation and rules; (e) maintain appropriate staff available on a 24-hour basis to respond to crisis situations, determine the severity of the situation, stabilize the eligible recipient, make referrals as necessary, and provide follow-up to the eligible recipient; and (f) consultation with oth to the eligible recipient in their self-administration of medication in compliance with state statute, regulation and rules; (e) maintain appropriate staff available on a 24-hour basis to respond to crisis situations, determine the severity of the situation, stabilize the eligible recipient, make referrals as necessary, and provide follow-up to the eligible recipient; and (f) consultation with other professionals or allied caregivers regarding the needs of the eligible recipient, as applicable. (4) Admission and treatment criteria based on the LOCUS level five criteria based on the dimensional evaluation of service needs. Length of stay duration is determined by medical necessity and ongoing LOCUS level five criteria and symptomology. The LOCUS levels of care are based on the intensity of clinical services, particularly as demonstrated by the degree of involvement of psychiatric, medical, and nursing professionals. The defining characteristic of LOCUS level five is that it serves recipients who need a medically monitored residential setting for stabilization and treatment. Recipients are transferred to lower levels of care when they have established sufficient skills to safely continue treatment at a lower level of care. (5) Sub-levels of level five level of care: (a) moderate intensity long term residential treatment services as specified in LOCUS level of care 5c are covered for recipients whose condition meets the criteria for LOCUS Level 5c and who are experiencing long term and persistent disabilities that require extended rehabilitation and skill building to develop capacity for community living: (b) moderate intensity intermediate stay residential treatment programs as specified in LOCUS levels of care 5b are covered for recipients whose condition meets the criteria of LOCUS level 5c and who need rehabilitation and skill building following stabilization of a crisis or to prevent precipitous deterioration in functioning ilitation and skill building to develop capacity for community living: (b) moderate intensity intermediate stay residential treatment programs as specified in LOCUS levels of care 5b are covered for recipients whose condition meets the criteria of LOCUS level 5c and who need rehabilitation and skill building following stabilization of a crisis or to prevent precipitous deterioration in functioning. (c) intensive short term residential services as specified in LOCUS level of care 5a are covered for recipients whose condition meets the criteria for LOCUS level 5a and who are stepping down from acute inpatient care or people who are in crisis but who do not require the security of a locked facility. 8.321.2 NMAC 11 C. Covered services: AARTCs treating all recipients meeting LOCUS level five criteria. MAD covers residential treatment services which are medically necessary for the diagnosis and treatment of an eligible recipient’s condition. A LOCUS level five AARTC facility must provide 24-hour care with trained staff. D. Non-covered services: AARTC services are subject to the limitations and coverage restrictions that exist for other MAD covered services. See Subsection G of 8.321.2.9 NMAC for general MAD behavioral health non-covered services or activities. MAD does not cover the following specific services billed in conjunction with AARTC services to an eligible recipient: (1) Comprehensive community support services (CCSS), except when provided by a CCSS agency in discharge planning for the eligible recipient from the facility; (2) Services for which prior approval was not requested and approved; (3) Services furnished to ineligible individuals; (4) Formal educational and vocational services which relate to traditional academic subjects or vocational training; and (5) Activity therapy, group activities, and other services primarily recreational or diversional in nature. E ing for the eligible recipient from the facility; (2) Services for which prior approval was not requested and approved; (3) Services furnished to ineligible individuals; (4) Formal educational and vocational services which relate to traditional academic subjects or vocational training; and (5) Activity therapy, group activities, and other services primarily recreational or diversional in nature. E. Treatment plan: The treatment plan must be developed by a team of professionals in consultation with the eligible recipient and in accordance with LOCUS and accreditation standards. The interdisciplinary team must review the treatment plan at least every 15 days. F. Prior authorization: Prior authorization is not required for up to five days for eligible recipients meeting LOCUS level 5 criteria to facilitate immediate admission and treatment to the appropriate level of care. Within that five day period, the provider must furnish notification of the admission and if the provider believes that continued care beyond the initial five days is medically necessary, prior authorization must be obtained from MAD or its designee. For out-of-state AARTCs prior authorization is required prior to admission. Services for which prior authorization was obtained remain subject to utilization review at any point in the payment process. All MAD services are subject to utilization review for medical necessity, inspection of care, and program compliance. Follow- up auditing is done by the accrediting agency per their standards. G. Reimbursement: An AARTC agency must submit claims for reimbursement on the UB-04 form or its successor. See Subsection H of 8.321.2.9 NMAC for MAD general reimbursement requirements and see 8.302.2 NMAC. Once enrolled, the agency receives instructions on how to access documentation, billing, and claims processing information. (1) MAD reimbursement covers services considered routine in the residential setting nt: An AARTC agency must submit claims for reimbursement on the UB-04 form or its successor. See Subsection H of 8.321.2.9 NMAC for MAD general reimbursement requirements and see 8.302.2 NMAC. Once enrolled, the agency receives instructions on how to access documentation, billing, and claims processing information. (1) MAD reimbursement covers services considered routine in the residential setting. Routine services include, but are not limited to, counseling, therapy, activities of daily living, medical management, crisis intervention, professional consultation, transportation, rehabilitative services and administration. (2) Services which are not covered in routine services include other MAD services that an eligible recipient might require that are not furnished by the facility, such as pharmacy services, primary care visits, laboratory or radiology services. These services are billed directly by the applicable providers and are governed by the applicable sections of NMAC rules. (3) MAD does not cover room and board. (4) Detailed billing instructions can be accessed in the BH policy and billing manual.