DownloadingTips
| What's new with EDI | Word | Adobe |
|---|---|---|
| ANSI ASC X12N 5010 Implementation Guides |
| EDI Forms | Word | Adobe |
|---|---|---|
| EDI Form Description / Usage | Not Available | PDF Format |
| EDI Provider Trading Partner Agreement | Word Format | PDF Format |
| EDI Submitter Trading Partner Agreement | Word Format | PDF Format |
| EDI Authorization Form | Word Format | PDF Format |
| EDI Update Form | Word Format | PDF Format |
| EDI Termination Form | Word Format | PDF Format |
| FAQ's | Word | Adobe |
|---|---|---|
| Provider / Submitter Not yet Enrolled in EDI | Not Available | PDF Format |
| Provider / Submitter Already Enrolled in EDI | Not Available | PDF Format |
| Link to Companion Guides |
| Topic | Word | Adobe |
|---|---|---|
| Questions and Answers about Health Care Information Forms for Individuals (Forms 1095-A, 1095-B, and 1095-C) | Not Available | Not Available |
Downloading Tips
| Topic | PowerPoint | Adobe |
|---|---|---|
| Influenza Vaccination 2019-2020 | Not Available | PDF Format |
| Medicaid provider audits | Not Available | PDF Format |
| RTC Medicaid Payment Reduction effective 12-01-09 | Not Available | PDF Format |
| Medicaid Enrollment Review-MAD 220 Form 2013 | Not Available | PDF Format |
| EHR Program Basics for Eligible Hospitals 2013 | Not Available | PDF Format |
| EHR Program Basics for Eligible Professionals 2013 | Not Available | PDF Format |
| Patient Volume for Eligible Professionals 2013 | Not Available | PDF Format |
| MAD 220 Form with 2012 V.1 Instructions | Not Available | PDF Format |
| Proposed Rule Amendments - Managed Care Program and Third Party Liability | Not Available | PDF Format |
| Centennial Care 2.0 FAQ | Not Available | Not Available |
Effective May 2, 2019, New Mexico Medicaid's Third Party Assessor and Utilization Review (TPA/UR) contractor, Qualis Health, began the process of changing their company name to Comagine Health.
The new name and logo below will appear on all correspondence letters and notifications sent by the TPA. The current website and email addresses will remain active and unchanged, however, in the near future, you may be redirected to the new Comagine website and email. The redirection will be in place for the remainder of the year to ensure a seamless transition.
The TPA's staff, phone numbers, fax numbers, and provider portal will not be impacted and will remain the same. If you have questions about the name change, please contact Comagine Health New Mexico at 505-217-7689 or visit the http://www.qualishealth.org/ for additional updates.
Comagine Health (previously Qualis Health) conducts prior authorization and utilization review services for the State of New Mexico - Human Services Department, Medical Assistance Division (HSD/MAD).
Programs/services include: Fee For Service Physical and Behavioral Health (including Alternative Benefit Plan); Mi Via waiver; Developmental Disabilities waiver; Medically Fragile waiver; Emergency Medical Services for Undocumented Aliens (EMSA); Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF-IID); and, the Program of All Inclusive Care for the Elderly (PACE).
Note: MCO related request or inquires must go to the appropriate MCO.
The Comagine Health (previously Qualis Health) website provides online resources with step by step instructions on how to successfully submit an authorization request or retrieve correspondence documents. Quick Start guides and training videos are also available on the Comagine Health (previously Qualis Health) website.
http://www.qualishealth.org/healthcare-professionals/new-mexico-medicaid/provider-resources
Technical assistance is available by calling Comagine Health (previously Qualis Health) at 1-866-962-2180. Business hours are Monday through Friday from 8:00 a.m. to 5:00 p.m. (Mountain Time).
Note: MCO related request or inquires must go to the appropriate MCO.
Emergency Medical Services for Aliens (EMSA) Claims ProcessEMSA provides coverage of emergency services for certain non-citizens who are undocumented or who do not meet the qualifying immigration criteria, and meet all eligibility criteria for an existing Medicaid category except for their alien status (Category of Eligibility 085).
EMSA claims can be submitted via the New Mexico Medicaid Web Portal or mailed to:
Conduent
P.O. Box 26500
Albuquerque, NM 87125-6500
Note:Paper claims must be original claim forms; copies will not be accepted and will be returned.
When submitting EMSA claims, please include the following documentation:
1. MAD-310 or MAD-778 form (Notification of Approval of Application for Emergency Medical Services for Aliens) or NOCA (Notice of Case
Action) from local Income Support Division office.
2. Pertinent medical records to determine the emergency medical condition.
Inpatient Facility:- MAD 310, MAD 778 or NOCA form (Dates on MAD 310, MAD 778 or NOCA form must match the dates of service on the claim)
- Admit History and Physical
- Emergency Department Records
- Discharge summary
- Any pertinent diagnostic imaging and/or lab results (if not included in H&P or Discharge Summary)
- Operative Notes (ONLY if Surgery was done)
- MAD 310, MAD 778 or NOCA form (Dates on MAD 310, MAD 778 or NOCA form must match the dates of service on the claim)
- History and Physical
- Operative Notes (ONLY if Surgery was done)
- Emergency Department Records
Note:The submitted claim documentation must match the patient's name that is on the MAD 310, MAD 778 or NOCA form.
Physician, Lab and Transportation:
It is not necessary for providers to attach a MAD 310, MAD 778 or NOCA to process EMSA claims for types Physician (P), Lab (L) and Transportation (T) as claim types will not pay without an approved Inpatient (I) or Outpatient (O) claim.
3. A cover letter with your contact information is recommended so we can contact you if necessary.
Please allow approximately 4 weeks for claims processing. Once processed, a claim status can be viewed on the New Mexico Medicaid Web Portal and on your Remittance Advice.
For questions regarding claim status, please call the Consolidated Customer Service Center (CCSC) at 1-800-299-7304 or via email at NM.Providers@state.nm.us.
For questions regarding EMSA medical reviews please contact Comagine Health (previously Qualis Health) TPA/UR toll-free Customer Service Line at 1-866-962-2180.
Reconsiderations may only be requested via fax or mail within 30 calendar days from the date of notice.
Reconsideration request may be sent to Comagine Health (previously Qualis Health) TPA via fax (888-562-2755) or mailed to:
Comagine Health (previously Qualis Health) TPA
Attn: EMSA Reconsideration Requests
PO Box 20910
Albuquerque, NM 87154-0910
For more information please refer to the New Mexico Administrative Code (NMAC) below:
NMAC 8.325.10 - Specialty Services for Emergency Medical Services for Aliens
https://www.hsd.state.nm.us/providers/rules-nm-administrative-code/
For more information please refer to the EMSA training below:
Emergency Medical Services for Aliens (EMSA)
Third Party Liability (TPL)
In some cases, Medicaid is the payer of last resort. Third party payers, such as group health insurance, auto liability insurance, worker's compensation, court-ordered health coverage, Medicare, etc., will pay first to the limit of their legal liability and then Medicaid will consider the claim for payment.
If you would like to report and/or update the TPL information on file with New Mexico Medicaid, please use the following contact information listed directly below:
For Clients: Call 1-888-997-2583
For Providers: Call 1-800-299-7304 or email at NM.Providers@state.nm.us.
Online Provider Enrollment and MCO-only Provider Registration
Click here to complete your Online Provider Participation Agreement (PPA) MAD 312 and 335 and Electronic Health Record (EHR) MAD220 online. Applications can be submitted for Fee-For-Service(FFS) and Managed Care Organization(MCO) network providers.
The benefits of applying online:
- Online applications are processed on average 3 weeks sooner than paper applications due to manual processing steps
- Step-by-step fill in the box entry with online edits to prevent common mistakes
- Easy upload of documents to accompany your application
- Applications are sent directly and immediately to Conduent Provider Enrollment
If you are unable to submit an application online, click the appropriate link to print the MAD335 or MAD312 paper application or contact the Consolidated Customer Service Center (CCSC) for assistance at 1-800-299-7304.
The Provider Type & Specialty Listing combinations are in the process of being updated in the online Provider Participation Agreement (PPA) applications. Providers may complete a paper application if the appropriate provider type and/or specialty is not available on the online enrollment application. Provider type and specialty listings should be available for online PPA applications in the next few weeks.
NM Medicaid is now accepting PROVISIONAL applications for temporary provider enrollment during the Public Health Emergency.Provisional Enrollment is temporary, not to be used for permanent enrollment of New Mexico Medicaid providers. Provisional enrollment will end after the Public Health Emergency.
The MAD Provisional Provider Participation Agreement (PPA) is intended for providers who are 1) providing COVID-19 related services to Medicaid recipients and 2) not currently enrolled in the New Mexico Medicaid program.
Please go to the Enroll Online page to create your application or recall an existing Provisional application on our web page.Submitting applications via the web portal will increase accuracy before submission and reduce turnaround time. Providers can also print, complete, and mail paper versions of the MAD 335 PROVISIONAL and MAD 312 PROVISIONAL by clicking on the link to the corresponding application.
Providers may be required to include licensure or certification documentation with the Provisional enrollment applications.
If you are unsure if you or your organization are already enrolled in the New Mexico Medicaid program, please use the Provider Search tool to verify status. If you have any further questions or need assistance, please contact the Consolidated Customer Service Center (CCSC) at 1-800-299-7304.
Downloading Tips| Topic | Word | Adobe |
|---|---|---|
| Provider Type & Specialty Listing | Excel Format | Not Available |
| New Mexico Provider Update Form | Word Format | Not Available |
| New Mexico Provider Update Instructions | Word Format | Not Available |
| Master Administrator Change Request Form | Not Available | PDF Format |
Selected Basic, Advanced and Specialty New Mexico Medicaid trainings or PowerPoint presentations are available below to:
- Learn on your own in the comfort of your home or office at your own pace and time
- Use as a guide or in a training with your staff
- Are available at no cost to NM Medicaid Providers
- Providers are able to attend any session.
- No preregistration is required, unless stated for the specific session
- See the latest New Mexico Medicaid E-News newsletter for registration information
| Topic | PowerPoint | Adobe |
|---|---|---|
| Web Registration, Master Adm. & User Presentation | PPT Format | PDF Format |
| Eligibility on the Web Portal Workshop | PPT Format | PDF Format |
| ADA Dental Online Claims Entry | PPT Format | PDF Format |
| DD Waiver CMS-1500 Online Claims Entry | PPT Format | PDF Format |
| CMS-1500 Claims Online Entry | PPT Format | PDF Format |
| UB-04 Online Claims Entry | PPT Format | PDF Format |
| Adjustment, Void and Rebill Online Claims Entry | PPT Format | PDF Format |
| JUST HEALTH (Justice-Involved Utilization of State Transitioned Healthcare) | PPT Format | PDF Format |
| IHS Tribal 638 Workshop | PPT Format | PDF Format |
| Topic | PowerPoint | Adobe |
|---|---|---|
| Reconsideration, Adjustment and Void Workshop | PPT Format | PDF Format |
| Family Planning | PPT Format | PDF Format |
| Medicaid School-Based Services Provider Training | PPT Format | PDF Format |
| Electronic Transactions Workshop | PPT Format | PDF Format |
| Provider Enrollment Workshop | PPT Format | PDF Format |
| Emergency Medical Services for Aliens (EMSA) | PPT Format | PDF Format |
| PE Determiner Portal Registration and Log on Workshop | PPT Format | PDF Format |
| Tab Run-Cost Audit Request Workshop | PPT Format | PDF Format |
| Online Provider Update | PPT Format | PDF Format |
| HIPAA 5010 Transactions Overview | PPT Format | PDF Format |
| Web Portal Electronic Transactions Overview | PPT Format | PDF Format |
| Behavioral Health Provider Enrollment Workshop | PPT Format | PDF Format |
For more information on HSD program policies, refer to: New Mexico Medical Assistance Division Program Policy Manual and Provider Packet Appendix for specific policy manual sections which apply to your specific provider type and specialty. Adjustments,Voids, and Inquiries
The following publications contain detailed instructions for filling out the Adjustment/Void Request Form (AVR) and the claim inquiry form. Downloading Tips
| Topic | PowerPoint | Adobe |
|---|---|---|
| Adjustment or Void Request Form | Word Format | PDF Format |
| Reconsideration Request Form | Word Format | PDF Format |
| Tab Run-Cost Audit Request Form | Word Format | PDF Format |
| Topic | Word | Adobe |
|---|---|---|
| MAD 046 Waiver Review Form | Not Available | PDF Format |
| MAD 054 Client Information Update | Not Available | PDF Format |
| MAD 056 EPSDT Personal Care Service Plan | Not Available | PDF Format |
| MAD 295 Medicaid Transportation Verification | Not Available | PDF Format |
| MAD 296 Medicaid Transportation Attestation | Not Available | PDF Format |
| MAD 302 Eye Services Prior Approval Request-Contact Lenses | Not Available | PDF Format |
| MAD 308 Emergency Medical Services for Aliens Referral For Eligibility Determination | Not Available | PDF Format |
| MAD 313 Notification of Birth Form | Not Available | PDF Format |
| MAD 316 Midwife Affidavit | Not Available | PDF Format |
| MAD 317 Supplemental Release and Indemnification Agreement | Not Available | PDF Format |
| MAD 318 Midwife Birthing Approval Form Confirmation/Release | Not Available | PDF Format |
| MAD 320 Hysterectomy Consent Form | Not Available | PDF Format |
| MAD 331 Title XIX Request for Prior Approval Inpatient Rehabilitation Services | Not Available | PDF Format |
| MAD 345 Sterilization Consent Form | Not Available | PDF Format |
| MAD 378 ICF MR Long Term Care Assessment Abstract | Not Available | PDF Format |
| MAD 379 Program of All-Inclusive Care for the Elderly (PACE) Long Term Care Medical Assessment | Not Available | PDF Format |
| Instructions in the use of revised MAD-295 - Medicaid Transportation Verification Form & MAD-296 - Medicaid Transportation Form | Not Available | PDF Format |
| NM Handicapping Labio-Lingual Deviations, #0000 | Not Available | PDF Format |
| MAD 394A Hearing Aid Evaluation Information | Not Available | PDF Format |
| MAD 634 Uniform New Mexico HCV Checklist | Not Available | PDF Format |
| MAD 635 Drug Authorization Request Form | Not Available | PDF Format |
| NM Standard Prior Authorization Form | Not Available | PDF Format |
| NM Medicaid FFS Payer Sheet with Covid Vaccines | Not Available | Word Format |
| Topic | Word | Adobe |
|---|---|---|
| CMS-1500 Professional Claim Form | Not Available | PDF Format |
| UB-04 Institutional Claim Form | Not Available | PDF Format |
| ADA 2012 Dental Claim Form | Not Available | PDF Format |
PE Phone Application Guidelines 2020
PED Training Slides 2020 Final 4.7.20
Downloading Tips
| Topic | Word | Adobe |
|---|---|---|
| MAD 008 - Household Size and Income Calculation Worksheet | Not Available | PDF Format |
| MAD 011 - Presumptive Eligibility (PE) Applicant Information Form | Not Available | PDF Format |
| MAD 029 - Aged Blind and Disabled Medicaid Programs | Not Available | PDF Format |
| MAD 070 - Medicaid Presumptive Eligibility Authorization Form | Not Available | PDF Format |
| MAD 100 - Medicaid Application for Assistance | Not Available | PDF Format |
| MAD 217 - PE Determiner Update | Not Available | PDF Format |
| MAD 222 - Federal Poverty Guidelines - Women, Children, & Family Medicaid Categories | Not Available | PDF Format |
| PE Determiner Portal Registration and Log on Workshop | PPT Format | PDF Format |
| SPANISH FORMS | ||
| MAD 011 SP - Formulario de Informacion Para la Solicitud de Probable Eligibilidad (Siglas en Ingles PE) | Not Available | PDF Format |
| MAD 100 SP - Solicitud Para Asistencia de Medicaid |
Not Available | PDF Format |
Electronic Visit Verification (EVV)
Communication to all providers:
Palco has published several resources to help you with utilizing Electronic Visit Verification (EVV) and ensuring a smooth payroll.
- For self-directed employees: Please ensure Palco has the most up to date Direct Deposit and W4 withholding information! You can update these at any time by submitting a Pay Selection Form or 2021 W-4 located on the Palco website. We highly encourage everyone to sign up for Direct Deposit or request a free Money Network Card to ensure fast and seamless payments. In addition to these forms, you can find the Payroll Resources Flyer with helpful information on ensuring your payroll is correct and accurate with Palco https://palcofirst.com/new-mexico/ to ensure that you are receiving stubs on time, please make sure your address is updated in Focos.
- For self-directed vendor providers: Please ensure that you are submitting a Payment RequestForm (PRF) to the EOR to ensure timely review and payment.
- For DDW and Supports Waiver agency providers: Please see https://palcofirst.com/new-mexico/
Beginning January 4th, 2021, please call 1-800-283-4465 and Press * for Electronic Visit Verification questions related to IVR logins or technical issues. Please call 1-800-283-4465 option 5 for Mi Via questions or issues. Call Center wait times may be longer than usual.
Weekly Communication:
Provider and Agency EVV Weekly Communication 05.19.21
SDCB EVV Weekly Communication 05.19.21
For immediate assistance please go to the following websites for EVV forms and resources:
Conduent-Palco Welcome Letter
EVV Frequently Asked Questions
Agency User Guide - Authenticare EVV Forum Q&A EVV Forum Q&A Addendum AuthentiCare EVV New Mexico Centennial Care Self-Directed Community Benefit Training-for-TrainersAuthentiCare Training Q&A
AuthentiCare SDCB Known Issues
EVV Telephony User Guide - Provider and Self-Directed Vendor Agencies
EVV Workstreams EVV Vendor Agency FAQ 2021 W-4 Form
Payroll Information Worksheet
Pay Selection and Direct Deposit Authorization
Mi Via & Supports Waiver Post Go-Live Information Session 1/15 - PDF
DDW & Supports Waiver Agency Based Post Go-Live Information Session 1/15 - PDF
EVV Post Go-Live FAQ - Self-Directed Community Benefits - 1/22/2021
EVV Post Go-Live FAQ - Mi Via & Supports Waiver - 1/15/2021
EVV Post Go-Live FAQ - DDW & Supports Waiver - 1/15/2021
EVV Agency Training Slides
EVV Provider and Agency Updates 3/3/21
Authenticare Mobile Application Instructions
Authenticare IVR Instructions
SDCB Providers EVV Weekly Communication 3/24/21
Provider and Agency EVV Weekly Communication 3/24/21
Authenticare SSPR Notice
SDCB Providers EVV Weekly Communication 04-07-21
Provider and Agency EVV Weekly Communication 04-07-21
SDCB EVV Weekly Communication_04.29.21
Provider and Agency EVV Weekly Communication_04.29.21
AuthentiCare NMCC SDCB EOR Guide Version 2.0
Self-Direction FMA Forms (Mi Via, Supports Waiver & Self-Directed Community Benefit)
Notice Regarding Lobby Closure
Please see Supplement #1: Fingerprinting Guidance for all new employees who are required to pass the NM Abuse Registry, Caregiver Online Registry (COR), and background checks for employment.
Downloading Tips