New Mexico Medically Necessary Services The following announcement regards the proposed New Mexico Department of Human Resources proposed new definition and application of Medically Necessary Services.

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The New Mexico Department of Human Services (NM HSD) is proposing to change the definition of Medically Necessary Services. This change will go through the formal rule making process and will include an opportunity for public comment. The NM HSD included the definition in its recent Request for Proposals. The Department instructed Officers to consider the following definition as part of their evaluation of the RFP.

NM HSD intends to propose the following rule change: Medically Necessary Services are services, which meet the requirements described in the definition. Both the definition and the application of the definition shall be utilized in the determination of medically necessary services.

Definition

Medically necessary services are clinical and rehabilitative physical, mental or behavioral health services that:

1. are essential to prevent, diagnose or treat medical conditions (e.g., illnesses, injuries, physical, mental and behavioral disorders, impairments or disabilities) and enable the enrollee to attain, maintain or regain functional capacity; and
    

2. are delivered in the amount, duration, scope and setting that is appropriate to the specific physical, mental and behavioral health care needs of the individual; and
    

3. are provided within professionally accepted standards of practice and national guidelines; and
    

4. are required to meet the physical, mental and/or behavioral health needs of the individual and are not primarily for the convenience of the individual, the provider or the payer.

Application of the Definition

1. medical necessity of clinical, rehabilitative and supportive services consistent with the Medicaid benefit package applicable to an eligible individual shall be determined by:
    

1. evaluating individual physical, mental and behavioral health information provided by qualified professionals who have personally evaluated the individual within their scope of practice, who have taken into consideration the individual’s clinical history including the impact of previous treatment and service interventions, and who have consulted with other qualified health care professionals with applicable specialty training, as appropriate; and
    

2. considering the views of the individual or the individual’s legal guardian, agent or surrogate decision maker regarding the proposed covered service as provided by the clinician or through independent verification of those views; and
    

3. considering the individual’s linguistic needs, cultural beliefs and practices, traditions and expressions of illness which affect diagnosis, treatment and outcome of interventions; and
    

4. considering the unique circumstances which may affect the accessibility or appropriateness of particular services for an individual; and
    

5. considering the services being provided concurrently by other service delivery systems; and
    

6. considering any choice expressed by the individual or the legal guardian, agent or surrogate about a service, provider and treatment location; and

2. Physical, mental and behavioral health services shall not be denied solely because the individual has a poor prognosis or has not shown improvement. Required services may not be arbitrarily denied or reduced in amount, duration or scope to an otherwise eligible recipient solely because of the diagnosis, type of illness or condition.
    

3. Decisions regarding benefit coverage for children shall be governed by the EPSDT coverage rules.

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