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 typically reimburses its providers based on the current CMS Medicare fee schedule. However, we may negotiate other reimbursement based on True Health New Mexico or provider needs. We may adopt reimbursement or methodology changes required by CMS guidance or federal or state laws/regulations, and we may incorporate annual CMS increases or decreases to the fee schedule. Although we primarily use the CMS fee schedule, we occasionally may process claims outside of the standardized CMS payment logic.

The primary fee schedules are:

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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:

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:

Facility “Overhead” Reimbursement Policy
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.

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:

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 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 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.

Find out more about True Health New Mexico’s reimbursement policies and procedures on our website at truehealthnewmexico.com/provider-reimbursement-policy.aspx.