Provider Reimbursement Policy

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. We reserve the right to review and update our Reimbursement Policies periodically.

Reimbursement and Fee Schedules

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
  • Hospice 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
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 1-844-508-4677.

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.

Provider-Based/Split Billing/Treatment Room Reimbursement Policy

Provider-based billing refers to the Medicare allowed practice of splitting bills for clinic and/or physician practices owned, controlled by or affiliated with a hospital. Under split billing, the hospital submits a bill for the technical component of the service on a UB-04 Hospital Claim form while the physician services are billed separately on a CMS-1500 Professional Claim form. Unless otherwise agreed upon in writing, True Health New Mexico will not reimburse for facility services billed on a UB-04. While True Health New Mexico may utilize Medicare fee schedules and CMS methodology to adjudicate claims, True Health New Mexico is not a Medicare entity, and does not recognize or reimburse facility overhead charges, provider-based or split billing. 

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 0510-0525 and 0527-0529 and any successor codes, including but not limited to the accompanying G Codes. 

True Health New Mexico will not separately reimburse for specialty services/treatment room revenue codes 0760-0769 when billed on a UB-04, or any other form. 

This policy applies regardless of whether or not the clinic uses the hospital tax identification number for claims and includes any services performed in an outpatient setting or clinic; regardless of if the clinic is an on-campus or off-campus outpatient hospital setting. 

The reimbursement for technical and overhead components of the facility clinic visit are included in the reimbursement paid to the professional provider for professional services, as reported on the CMS-1500 form. This includes, but is not limited to, place of service codes 11, 20, and 22. These services may encompass but are not limited to Evaluation and Management health care 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 its 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 the Agreement with True Health New Mexico, True Health New Mexico reserves the right to recover overpayments resulting from separately billed clinic/facility fees billed in combination with a professional office/clinic visit claim.

Provider-based billing claim refers to a claim submitted with at least one service including, but not limited to: Surgery, lab, radiology, drugs and supplies billed with revenue codes 0510-0529 or with revenue codes 0760-0761 and E&M Office Visit CPT/HCPCS codes, including but not limited to, 99200-99205; 99211-99215; 99241-99245; 99354,99355, 99381-99387, 99391-99391, 99401-99412, 99429, 99450, 99455-99456, 99487-99489, 99499. 

Some examples of a facility clinic visit billed on a UB-04 which include non-covered revenue codes include, but are not limited to, situations when a member:

  • Receives procedures such as dialysis or emergency department procedures in a clinic. 
  • Listed revenue codes billed in conjunction with PICC line insertion.
  • Listed revenue codes billed in conjunction with a Procedure (CPT) in addition to Cast Room, the Cast Room is not separately reimbursable.
  • Listed revenue codes billed in conjunction with insertion of a peripheral IV, the treatment room is not separately reimbursable.
ICD-10 Information

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.

Code Description Comment
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.

Other Information
Ancillary Services

  • 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.

Emergency Services

  • 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.

Inpatient Admissions

  • 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.

Surgical Procedures

  • 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