Emergency Medical Services for Aliens
Medicaid covers emergency services for certain non citizens who are undocumented or who do not meet the qualifying immigration criteria specified in 8.200.410.11 NMAC, citizenship, but who meet all eligibility criteria for one of the categories noted in 8.285.400 NMAC, Recipient Policies, except for citizenship or legal alien status. After the receipt of an emergency medical service from a New Mexico Medicaid provider, the individual is referred to and must submit a Medicaid application to the local Income Support Division (ISD) county office for an evaluation of Medicaid eligibility. Once an eligibility determination is made, the individual will be notified by ISD of approval or denial of eligibility. If the individual is eligible for EMSA services, the individual must notify the servicing provider of approval by providing the MAD 310 (Notification of Approval Form) to the provider, so that the claim can be submitted to the Medical Assistance Division’s designee for the emergency services evaluation and claim payment.
Provider submissions or requests for review for EMSA must be accompanied by form MAD 310, the appropriate billing form (UB-04 or CMS 1500), summary of charges, and the pertinent medical records to determine the emergency medical condition that required immediate medical attention. The provider billing forms (UB-04 or CMS 1500) must be original forms, copies will not be accepted.
Effective December 1, 2009, all EMSA claims must be sent to Affiliated Computer Services (ACS), the Medicaid fiscal intermediary, for processing. You can contact ACS at the following link, https://nmmedicaid.acs-inc.com/static/index.htm/index.htm
Definition of "Emergency"
"Emergency" is defined by HSD/MAD as a medical condition, including all emergency labor and delivery, which includes emergency inductions and unscheduled cesarean sections, manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in the individual's death, or placing the individual's health in serious jeopardy, or serious impairment of bodily functions, or serious dysfunction of any bodily part or organ. Only those services that meet this definition can be covered for the duration of the emergency.
HSD/MAD does not cover any medical service that is not necessary to treat or evaluate a condition for an individual who is an undocumented alien that does not meet the definition of emergency. Additionally, HSD/MAD does not cover the following specific services:
A. long term care;
B. organ transplants;
C. rehabilitation services;
D. elective surgical procedures;
E. psychiatric or psychological services;
F. durable medical equipment or supplies;
H. hearing aids;
I. outpatient prescriptions;
J. podiatry services;
K. prenatal and postpartum care;
L. well child care;
M. routine dental care;
N. routine dialysis services;
O. any medical service furnished by an out-of-state provider;
P. non-emergency transportation; and
Q. preventive care.
If services do not meet the definition of a medical emergency and they are denied by the medical reviewer, a completed MAD 307(Denial of Claims Emergency Medical Services for Aliens) form is sent to the provider and the recipient of services.
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