Provider Reimbursement Policy
Reimbursement and Fee Schedules
These policies apply to all True Health New Mexico plan products. The member’s contracted health plan benefits must be in effect on the date that services are rendered. True Health New Mexico reserves the right to review and update our Reimbursement Policies periodically.
True Health New Mexico reimburses its providers based on the current CMS Medicare fee schedule. We will adopt any reimbursement or methodology changes required by CMS guidance or federal or state laws/regulations, and we do incorporate annual CMS increases or decreases to the fee schedule. Although we use the CMS fee schedule, we occasionally may process claims outside of the standardized CMS payment logic.
The primary fee schedules are:
CMS Inpatient Prospective Services (IPPS)
CMS Outpatient Prospective Services (OPPS)
Physician Fee Schedule (MPFS)
Durable medical equipment, prosthetics and orthotics, and supplies (DMEPOS)
CMS Laboratory Fee Schedule
CMS Average Sales Price (ASP)
Home Health PPS
Other applicable CMS fee schedules
To calculate your reimbursement, go to the easy-to-use CMS lookup tool. Enter your code to calculate 100 percent of reimbursement. Be sure to apply your contracted allowable, if applicable.
In all cases, it is True Health New Mexico’s policy to reimburse providers the lesser of the provider’s billed charge or the provider’s contracted reimbursement rate.
Reimbursement of Covered Non-Contracted Goods and Services
It is True Health New Mexico’s policy to reimburse, rather than to deny claims payment to, contracted network providers when the provider submits claims for goods or services without a negotiated provision for those specific goods and services within the provider’s contract with True Health New Mexico.
Reimbursement is contingent on the goods or services being a covered benefit, and contingent on the provider following True Health New Mexico guidelines for obtaining health plan authorization for the good or service, or providing the appropriate notification to the health plan prior to the service rendered. Providers must also treat members within their scope of practice specialty.
The following are a few examples of covered non-contracted goods or services:
Durable Medical Equipment (DME) (goods) issued to a member without a negotiated DME provision within the provider’s contract with True Health New Mexico.
Infusion drugs (goods and/or services) administered to a member without a negotiated provision for drugs or “J” codes within the provider’s contract with True Health New Mexico.
Lab tests drawn and/or tested by provider or provider’s lab with no negotiated lab provision within the provider’s contract with True Health New Mexico.
While True Health New Mexico is not a CMS entity, True Health New Mexico will utilize the lesser of the provider’s billed charge, or CMS’s reimbursement methodology and fee schedules, to administer usual and customary payment for covered non-contracted goods and services.
The following are examples of, but not limited to, the fee schedules True Health New Mexico uses use to administer payment of covered non-contracted goods and services:
CMS DMEPOS: Durable Medical Equipment and Prosthetics and Orthotics
CMS ASP: Drugs, Infusion, Injectables
CMS CLFS: Clinical Laboratory Fee Schedule
Administrative Denial for Failure to Obtain a Prior Authorization for a Non-Emergent Service
True Health New Mexico does not retroactively authorize elective services, procedures, or admissions.
Providers must obtain prior authorization for an elective service, procedure, or admission prior to rendering services. If the service provided is urgent or emergent in nature, and the rendering provider is unable to request authorization in advance, True Health New Mexico will consider retroactive authorization. True Health New Mexico will deny payment for authorizations requested after elective services have been performed, and providers may not bill members for this service. The provider may submit a request for reconsideration upon claim denial via the True Health New Mexico appeals process.
True Health New Mexico is dedicated to the efficient and timely management of healthcare service requests when a provider has failed to follow prior authorization requirements. When we issue an administrative denial for this reason, we adhere to the True Health New Mexico Administrative Decisions Policy and Procedure.
Facility “Overhead” Reimbursement Policy
While True Health New Mexico utilizes Medicare fee schedules and CMS methodology to adjudicating claims, True Health New Mexico is not a Medicare entity, and does not recognize or reimburse Facility Overhead Charges.
A Facility Overhead Charge is a clinic charge for any technical component or overhead that is billed by a facility when a professional provider renders covered services to True Health New Mexico members in a facility clinic setting.
True Health New Mexico defines a facility clinic visit as a preventive, curative, diagnostic, rehabilitative, and/or education service provided to an ambulatory patient in an outpatient setting, whether in a freestanding or attached facility that is either owned, operated, leased, or controlled by the facility.
Some examples of a facility clinic visit include, but are not limited to a member:
- Having blood drawn for lab work at a facility draw station
- Seeing a behavioral health provider on a hospital campus
- Getting an X-ray at a diagnostic center
- Seeing his or her PCP
- Receiving education from a nutritionist
True Health New Mexico reimburses professional providers for covered services provided in a facility clinic setting when filed on a CMS-1500 form with place of service codes to include, but not limited to, place of service 11, 20, or 22 (Office, Urgent Care, Outpatient). This reimbursement will always include both the professional services and the associated overhead.
True Health New Mexico will not separately reimburse a facility for facility clinic visits and services billed on a UB-04, or any other form, when reported with revenue codes 510-525, 527-529 and any successor codes, including but not limited to the accompanying G Codes.
The technical and overhead component of the facility clinic visit will be included by True Health New Mexico in the reimbursement paid to the professional provider for professional services, as reported on the CMS-1500 form, with place of service codes to include, but not limited to, place of service 11, 20, or 22. These services may encompass but are not limited to Evaluation and Management healthcare services provided to True Health New Mexico members in a clinic setting.
The facility may not seek reimbursement for any technical or overhead component of the clinic charge from True Health New Mexico or from our members. The member is held harmless and may not be balance-billed by the provider for clinic facility charges.
In accordance with the terms of your Agreement with True Health New Mexico, we reserve the right to recover overpayments resulting from separately billed clinic/facility fees billed in combination with a professional office/clinic visit claim.
Claims Processing and Payment
Please file claims within 90 days following the date of service or hospital discharge date.
- Complete standard claim forms and use current CPT-4/HCPC and Revenue Code guidelines.
- Submit claims electronically through your local vendor or True Health New Mexico’s clearinghouse, or submit paper claims to the appropriate address located on the back of the member’s ID card.
- True Health New Mexico prices the claim based upon the lesser of provider’s billed charges or the contractual allowance.
- True Health New Mexico’s payor determines benefits and eligibility and then issues a remittance advice report to the participating physician, hospital, or healthcare professional.
- True Health New Mexico encourages hospitals and healthcare professionals to submit electronic claims.
Additional tips for submitting claims:
- Submit clean claims on a CMS-1500 form or UB04 form that is compliant with National Provider Identifier (NPI) and Health Insurance Portability and Accountability Act (HIPAA) regulations. Valid CPT, Revenue, HCPCS, ASA, and ICD-9/ICD-10 codes must be used and include appropriate modifiers, if applicable.
- Important: True Health New Mexico requires that providers submit claims for all HCPCS drug codes (J-codes) with the corresponding valid national drug code (NDC). Make sure that a valid NDC is listed on the claim line that contains the HCPCS drug code. If the NDC is missing, the claim line will be rejected. The Food and Drug Administration publishes NDC numbers at http://www.fda.gov/drugs/informationondrugs/ucm142438.htm. This publication is updated daily.
- True Health New Mexico may require additional information for particular types of services, or based on particular circumstances or state requirements.
- Some claims may require supporting information for initial review. True Health New Mexico will request additional information when needed.
For questions about claims, filing, or contracted reimbursement, please contact True Health New Mexico’s customer care center at 1-855-769-6642.
On October 1, 2015, the healthcare industry changed from ICD-9 to ICD-10 codes for diagnoses and inpatient procedures. This transition involvex new coding rules, so it is important for providers to obtain the latest coding manuals and to submit claims in ICD-10 format.
True Health New Mexico is committed to helping providers implement ICD-10 successfully. We recommend that providers visit the CMS website for ICD-10 tutorials and updates.
Treatment Room Reimbursement Policy
Treatment Room Services consist of those outpatient services, furnished on hospital premises, that require the use of a bed and periodic clinical monitoring by licensed personnel for relatively brief periods of time to carry out specific nonsurgical procedures that are not customarily performed in specialized suites that are otherwise billable. Recovery services related to the effects of such procedures are appropriate uses of treatment rooms. The use of the treatment room may represent an expected part of a minor procedure and replaces the charge for operating room and recovery room.
True Health New Mexico reimburses treatment room services only when a specific, identifiable procedure has been performed or a treatment rendered that is unrelated to inpatient or outpatient services provided within the contracted global reimbursement period. The treatment room services must be directly related to the procedures that are provided on the same day in which the treatment is rendered.
An order is required for treatment room services, and True Health New Mexico requires notification and authorization for treatment room services that result in inpatient or observation admission stays.
Billing for treatment room is not appropriate for the following services or settings:
Diagnostic procedures, other than those directly related to the performance of a surgical procedure
Durable medical equipment (DME) for member’s home use
Leg, arm, back, or neck braces
Treatment room services that are rendered for the sole purpose of performing laboratory, radiology, or other diagnostic testing
Treatment room services rendered as part of an inpatient stay within 24 and 72 hours of admission
Outpatient observation stays
Emergency room visits
Urgent care visits
Services are always subject to applicable member copayment, coinsurance, or deductible.
|0760||Treatment/Observation Room||Not applicable for treatment room billing.|
|0761||Treatment Room||Revenue code 0761 is not reimbursable unless appropriately billed as directed in the UB-04 Editor. Revenue code 0761 must be for the actual use of a treatment room in which a specific procedure has been performed or a treatment rendered. Do not bill Evaluation & Management (E&M) CPT codes with revenue code 0761. Allowance or disallowance for this revenue code may be determined by medical record review.|
|0769||Treatment/Observation Room||Not applicable for treatment room billing.|
Bill ancillary services using appropriate ancillary revenue codes and HCPCS codes on the same UB-04 form or electronic 837I, version 5010 as the treatment room charge.
Bill diagnostic, radiology, and laboratory services on separate lines from the treatment room revenue code.
- Bill emergency room services that result in a subsequent treatment room visit or a treatment room service that results in a subsequent emergency room visit, on the same UB-04 form or electronic 837I, version 5010 as the emergency room charges using revenue code 761.
- Bill treatment room services that result in an inpatient admission on the same UB-04 form or electronic 837I, version 5010 as the inpatient admission, using revenue code 761.
Bill treatment room services that result in a subsequent surgical procedure on the same UB-04 form or electronic 837I, version 5010 as the surgical procedure.
Bill surgical procedures that result in the subsequent use of a treatment room on the same UB-04 form or electronic 837I, version 5010 as the treatment room.
Rehabilitative and Habilitative Services Reimbursement Policy
Rehabilitative/Habilitative Services: Definitions and Prior Authorization
Rehabilitative services are defined as skilled, medically necessary, health care services that help a member redevelop, maintain, or improve skills and functioning required for activities of daily living that have been lost or impaired due to illness, injury, or disability. Rehabilitative services must be part of a prescribed plan of treatment to regain function or maintain a member’s current condition and prevent further decline. Rehabilitative services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings. Rehabilitative services must be performed by a physician or a licensed therapy provider. They can be denied or shortened for members who are not progressing in goal-directed rehabilitation services, or if rehabilitation goals have previously been met.
Habilitative services are defined as skilled, medically necessary healthcare services that help a member learn, maintain, or improve skills and functioning required for activities of daily living. Habilitative services must be part of a prescribed plan of treatment that is deemed medically necessary to maintain a member’s current condition or to prevent or slow further decline. These services are NOT custodial care delivered for the purpose of assisting a member with activities of daily living. Examples of habilitative services include therapy for a child who isn’t walking or talking at the expected age. Habilitative services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings. Habilitative services can be denied or shortened for members who are not progressing in goal-directed habilitative services or if habilitative goals have previously been met.
Services that are rehabilitative or habilitative, according to the definitions above, require prior approval and are not subject to visit limitations or benefit limits. Authorization is required to demonstrate that the services meet the definition and are part of a prescribed comprehensive plan of treatment, and that the member continues to progress toward defined goals. Medically necessary rehabilitative and habilitative services that receive prior authorization will be reimbursed according to the provider contract, but are not subject to benefit limits.
Acupuncture, Chiropractic, and Short-Term Rehabilitation Therapy
Acupuncture services must be appropriate for the treatment of a condition that is covered by True Health New Mexico. Coverage for members is limited to twenty (20) visits per calendar year. Acupuncture services that are habilitative or rehabilitative require prior approval and are not subject to the visit limitations.
Chiropractic services must be appropriate for the treatment of a condition that is covered by True Health New Mexico. Coverage is limited to twenty (20) visits per calendar year. Chiropractic services that are habilitative or rehabilitative require prior approval and are not subject to the visit limitations.
Short-Term Rehabilitation Therapy
Short-Term rehabilitation therapy may include physical, speech, occupational, cardiac, and pulmonary therapy. These therapies are covered when True Health New Mexico has determined that they are expected to result in significant improvement of a member’s physical condition within two (2) months of beginning therapy. These services may be needed as a result of an injury, surgery, or acute medical condition. Related occupational therapy is provided for the purpose of training members to perform the activities of daily living. Services require prior approval after ten (10) visits.
True Health New Mexico does not reimburse non-medical ancillary services such as vocational or educational rehabilitation, behavioral training, sleep therapy, job counseling, psychological counseling and training, or educational therapy for learning disabilities or mental impairment.