Section 27-11-15 – Disposition of recovered medicaid funds.
A. Overpayments collected pursuant to the Medicaid Provider and Managed Care Act on behalf of the state shall be remitted to the department for deposit in the general fund to be used for the state’s medicaid program. B. The department shall not enter into a contract to pay any portion of funds recovered by the […]
Section 27-11-16 – Credible allegation of fraud; judicial review; substantial evidence required.
A. A credible allegation of fraud determination by the department shall be deemed a final agency decision and may be appealed pursuant to Section 39-3-1.1 NMSA 1978. B. A medicaid provider or subcontractor that is the subject of a referral to the attorney general for further investigation based on a credible allegation of fraud may […]
Section 27-11-17 – Award of costs, fees and interest.
A. If a medicaid provider or subcontractor is the prevailing party in any expedited adjudicatory or court proceeding brought by the medicaid provider or subcontractor pursuant to the Medicaid Provider and Managed Care Act on or after January 1, 2020 in connection with a preliminary or final determination of overpayment or a determination of credible […]
Section 27-11-18 – Applicability of Administrative Procedures Act.
A. The department shall be subject to Sections 12-8-2, 12-8-10 through 12-8-13, 12-8-15 and 12-8-16 NMSA 1978 for expedited adjudicatory proceedings as provided by the Medicaid Provider and Managed Care Act. B. Sections 12-8-2, 12-8-10 through 12-8-13, 12-8-15 and 12-8-16 NMSA 1978 apply to Sections 5 [22-11-7 NMSA 1978], 7 [27-11-9 NMSA 1978] through 11 […]
Section 27-11-12 – Rights of medicaid provider or subcontractor; preliminary or final determination of overpayment.
A. A medicaid provider or subcontractor may challenge: (1) the department’s preliminary or final determination of overpayment as: (a) exceeding statutory authority; (b) arbitrary or capricious; (c) a failure to follow department procedure; or (d) not supported by substantial evidence; (2) the credentials of persons who participated in the audit or claims review; or (3) […]
Section 27-11-13 – Release of suspended payment for services previously rendered; prepayment review; remedial training and education; temporary assistance.
A. The department shall direct the release of a suspended payment to a medicaid provider or subcontractor that is the subject of a referral based upon a determination of a credible allegation of fraud for services previously rendered if the medicaid provider or subcontractor posts a surety bond in the amount of the suspended payment, […]
Section 27-11-14 – Maintenance of services; payment for ongoing services.
A. Following the referral of a medicaid provider or subcontractor based on a determination of a credible allegation of fraud, and during the pendency of a dispute between the department and a medicaid provider or subcontractor regarding an alleged overpayment, including an overpayment based in whole or in part on a credible allegation of fraud, […]
Section 27-11-5 – Rules.
The secretary shall adopt and promulgate rules appropriate to administer, carry out and enforce the provisions of the Medicaid Provider Act. History: Laws 1998, ch. 30, § 5.
Section 27-11-6 – Repealed.
History: Laws 2004, ch. 4, § 1; repealed by Laws 2006, ch. 25, § 2. ANNOTATIONS Repeals. — Laws 2006, ch. 25, § 2 repealed 27-11-6 NMSA 1978, as enacted by Laws 2004, ch. 4, § 1, relating to the imposition of a daily bed surcharge, effective March 2, 2006. For provisions of former section, […]
Section 27-11-7 – Determination of overpayments or credible allegation of fraud; audit findings; sampling; extrapolation limited; notice of right to informal conference and expedited adjudicatory proceeding.
A. The department may audit a medicaid provider or subcontractor for overpayment, using sampling for the time period audited. If the department contracts for the audit, the department shall contract only with an independent auditor approved by the state auditor. Each audited claim shall be reviewed by a person who is licensed, certified, registered or […]