Provider Information
Electronic Data Exchange (EDI)
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What's new with EDI Word Adobe
ANSI ASC X12N 5010 Implementation Guides
EDI Forms Word Adobe
EDI Form Description / Usage Word Format 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
1095 Information
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
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Important State Announcements
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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
Proposed Rule Amendments - Managed Care Program and Third Party Liability Not Available PDF Format
Centennial Care 2.0 FAQ Not Available Not Available
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New Mexico Medicaid Third Party Assessor/Utilization Review for Fee-For-Service

Comagine Health has completed their website migration.

Effective July 1, 2021, the New Mexico Medicaid webpages on qualishealth.org will move to the new website.

The new web address is https://comagine.org/program/new-mexico-medicaid.

New Mexico Medicaid webpages on the Qualis Health website will be automatically redirected to the new Comagine Health website for the first year. After July 2022, automatic redirections will not occur so please save the new website for future reference.

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 Non-Citizens (EMSNC); 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.

            https://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 Non-Citizens (EMSNC) Claims Process

MR 21-09 - ALIEN NAME CHANGE TO NON-CITIZENS AND UPDATE TO MAD EMERGENCY MEDICAL SERVICES FOR ALIENS (EMSA) FORMS

EMSNC 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 non-citizen status (Category of Eligibility 085).

EMSNC 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 EMSNC claims, please include the following documentation:

    1.   MAD-310 or MAD-778 form (Notification of Approval of Application for Emergency Medical Services for Non-Citizens) 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)
    Outpatient services:
  • 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 EMSNC 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 EMSNC 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: EMSNC 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 Non-Citizens

https://www.hsd.state.nm.us/providers/rules-nm-administrative-code/

For more information please refer to the EMSNC training below:

Emergency Medical Services for Non-Citizens (EMSNC)

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.

Provider Enrollment
NPI: What You Need to Know (cms.gov)
The NPI is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Standard. An NPI is a unique identification number for covered health care providers, created to improve the efficiency and effectiveness of electronic transmission of health information. Covered health care providers, all health plans, and health care clearinghouses must use NPIs in their administrative and financial transactions. The HIPAA Administrative Simplification provisions required the adoption of a standard, unique health identifier for each health care provider. The NPI Final Rule, published on January 23, 2004, established the NPI as this standard. CMS developed the National Plan and Provider Enumeration System (NPPES) to assign these unique identifiers. For more information on how to apply for an NPI, refer to the NPPES webpage NPPES (hhs.gov).
Topic PowerPoint Adobe
Provider Enrollment Workshop PPT Format PDF Format
Behavioral Health Provider Enrollment Workshop PPT Format PDF Format
Online Provider Update PPT Format PDF Format
Online Provider Enrollment and MCO-only Provider Registration
Click here to complete your Online Provider Participation Agreement (PPA) MAD 312 and 335 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.

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.

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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
(As part of the enrollment process, you must fill out IRS form W-9. Go to https://www.irs.gov/ to download a copy of the form.)
Training Presentations
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
Live Provider Webinar Sessions:
  • 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
DownloadingTips
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
Emergency Medical Services for Non-Citizens (EMSNC) 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
HIPAA 5010 Transactions Overview PPT Format PDF Format
Web Portal Electronic Transactions Overview PPT Format PDF Format
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Forms, Publications, and Instructions
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.
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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
Authenticare Adjustment or Void Request Form Word Format PDF Format
HSD/MAD Forms
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 307 Emergency Medical Services for Non-Citizens Denial of Claims Not Available PDF Format
MAD 308 Emergency Medical Services for Non-Citizens 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 635 Drug Authorization Request Form Not Available PDF Format
MAD 872 Community Health Workers (CHW) and Community Health Representatives (CHR) Services Not Available PDF Format
MAD 901 NM Qualified Clinical Trial Medicaid Attestation 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
Box by Box Instructions for Completing Claim Forms
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
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Presumptive Eligibility Determiner (PED) forms and Training
PE Phone Application Guidelines 2020

PED Training Slides 2020 Final 4.7.20

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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
MAD 628 - How to Determine a Household Size 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/

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Self-Direction FMA Forms (Mi Via, Supports Waiver & Self-Directed Community Benefit)


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Topic Word Adobe
EMPLOYEE FORMS
DHI Authorization for Release of Information Not Available PDF Format
Employee 2-Week Mileage Not Available PDF Format
Employee 2-Week Timesheet Not Available PDF Format
Form W-4 for Federal Withholding Not Available PDF Format
Form W-4 for Federal Withholding - Spanish Not Available PDF Format
Form W-4 for New Mexico Withholding Not Available PDF Format
Form W-4 for New Mexico Withholding - Spanish Not Available PDF Format
I-9 Not Available PDF Format
Self Direction Provider Attestation form CMS Final Rule Not Available PDF Format
2024 Employee Payroll Schedule Not Available PDF Format
2024 Employee Payroll Schedule - Spanish Not Available PDF Format
Palco Employee Agreement Not Available PDF Format
Palco Employee Agreement - Spanish Not Available PDF Format
Palco Employee Direct Deposit Not Available PDF Format
Palco Employee Information Form Not Available PDF Format
Palco Employee Packet Not Available PDF Format
Palco Employee Packet - Spanish Not Available PDF Format
Palco Employee Payroll Information Worksheet Not Available PDF Format
Palco Employee Qualification Form Not Available PDF Format
Palco Employee Transportation Appendix Not Available PDF Format
Legally Responsible Individual Form Not Available PDF Format
Pre-Hire Packet Not Available PDF Format
Pre-Hire Packet - Spanish Not Available PDF Format
MISCELLANEOUS FORMS
Shell Request Form Not Available PDF Format
Authorization to Sign Vendor Agreements and Payment Request Forms When There is No Employer of Record Not Available PDF Format
Goods and Services Explanation Letter for Vendors Not Available PDF Format
Hiring an Employee Not Available PDF Format
Request for Exception to Online Submission of Timesheets Not Available PDF Format
Self-Direction Appointment of Authorized Agent or Personal Representative Not Available PDF Format
Using Vendor Checks Not Available PDF Format
Self-Direction Appointment of Authorized Representative Not Available PDF Format
Palco Employer Packet Not Available PDF Format
Palco Employer Packet - Spanish Not Available PDF Format
Palco Employer's Information & Responsibilities Not Available PDF Format
NM Payroll Resources Flyer Not Available PDF Format
Mi Via COVID-19 Emergency Over 40hrs. Request Form Not Available Word Format
Mi Via COVID-19 Emergency Over 40hrs. Timesheet Not Available Word Format
Stop Payment and Check Reissue Request Form Not Available PDF Format
Stop Payment and Check Reissue Request Form - Spanish Not Available PDF Format
Money Network Card Reimbursement Request Form Not Available PDF Format
Money Network Card Reimbursement Request Form - Spanish Not Available PDF Format
Money Network Card (MNC) Frequently Asked Questions (FAQ) Not Available PDF Format
Money Network Card (MNC) Request Packet- For Employers Not Available PDF Format
Money Network Card (MNC) Validation Outreach Coversheet Not Available PDF Format
Change of Information Form Not Available PDF Format
Change of Information Form - Spanish Not Available PDF Format
Palco Employment Separation Notice Not Available PDF Format
Palco Employment Separation Notice - Spanish Not Available PDF Format
VENDOR FORMS
Non-Timesheet Invoice Not Available PDF Format
Vendor Form: W-9 Form and Instructions Not Available PDF Format
2024 Vendor Payroll Schedule Not Available PDF Format
2024 Vendor Payroll Schedule - Spanish Not Available PDF Format
Palco Vendor Agreement Not Available PDF Format
Palco Vendor Direct Deposit Not Available PDF Format
Palco Vendor Mileage Invoice Not Available PDF Format
Palco Vendor Mileage Invoice - Spanish Not Available PDF Format
Palco Vendor Packet Not Available PDF Format
Palco Vendor Packet - Spanish Not Available PDF Format
Palco Vendor Payment Request Not Available PDF Format
Palco Vendor Transportation Appendix Not Available PDF Format
Palco Employer Transition Packet Not Available PDF Format
Palco Pay Selection and Direct Deposit Authorization - Vendors Not Available PDF Format
Palco Pay Selection and Direct Deposit Authorization - Vendors - Spanish Not Available PDF Format
Palco Vendor Information Form Not Available PDF Format
Palco Vendor Information Form - Spanish Not Available PDF Format
Palco Vendor Qualification Form Not Available PDF Format
Vendor Separation Notice Not Available PDF Format
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