Section 25. Reimbursement

A NF provider must submit claims for reimbursement on the long term care turn around document (TAD) or its successor; see 8.302.2 NMAC. A. MAD reimburses a NF at the lesser of the following: (1) the NF’s billed charges; 8.312.2 NMAC 10 (2) the prospective reimbursement rates constrained by the ceilings established by MAD; see 8.312.3 NMAC; and (3) the NF’s billed charge must be its usual and customary charge for services; “usual and customary charge” refers to the amount which the individual provider charges the general public in the majority of cases for a specific procedure or service. B. Reimbursement limitations: Payments are made only to a MAD enrolled, and as appropriate a HCA MCO contracted NF. Payments to a NF are limited to those service costs which are included as allowable costs under approved provisions of the medicaid state plan or the MAD alternative benefit; see 8.312.3 NMAC. All claims for payment from MAD or the MCO are subject to utilization review and control. C. Reimbursement methodology: See 8.312.3 NMAC for a detailed description of this methodology.