New Mexico § 27-11-2 Definitions

New Mexico Statutes

§ 27-11-2 — Definitions

New Mexico § 27-11-2

Ch. 27Public Assistance

Art. 11Medicaid Providers

This text of New Mexico § 27-11-2 (Definitions) is published on Counsel Stack Legal Research, covering New Mexico primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook

N.M. Stat. Ann. § 27-11-2 (2026).

Text

As used in the Medicaid Provider and Managed Care Act: A. "claim" means a request for payment for services; B. "clean claim" means a claim for reimbursement that:

(1)contains substantially all the required data elements necessary for accurate adjudication of the claim without the need for additional information from the medicaid provider or subcontractor;

(2)is not materially deficient or improper, including lacking substantiating documentation required by medicaid; and (3) has no particular or unusual circumstances that require special treatment or that prevent payment from being made in due course on behalf of medicaid; C. "credible" means having indicia of reliability after the state has reviewed all allegations, facts and evidence carefully and acted judiciously on a case-by-case bas

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As used in the Medicaid Provider and Managed Care Act: A. "claim" means a request for payment for services; B. "clean claim" means a claim for reimbursement that: (1) contains substantially all the required data elements necessary for accurate adjudication of the claim without the need for additional information from the medicaid provider or subcontractor; (2) is not materially deficient or improper, including lacking substantiating documentation required by medicaid; and (3) has no particular or unusual circumstances that require special treatment or that prevent payment from being made in due course on behalf of medicaid; C. "credible" means having indicia of reliability after the state has reviewed all allegations, facts and evidence carefully and acted judiciously on a case-by-case basis; D. "credible allegation of fraud" means an allegation that has been verified by the state from any source, including fraud hotline complaints, claims data mining and provider audits; E. "department" or "authority" means the health care authority; F. "fraud" means any act that constitutes fraud under state or federal law; G. "managed care organization" means a person eligible to enter into risk-based prepaid capitation agreements with the authority to provide health care and related services; H. "medicaid" means the medical assistance program established pursuant to Title 19 of the federal Social Security Act and regulations issued pursuant to that act; I. "medicaid provider" means a person that provides medicaid-related services to recipients; J. "overpayment" means an amount paid to a medicaid provider or subcontractor in excess of the medicaid allowable amount, including payment for any claim to which a medicaid provider or subcontractor is not entitled; K. "person" means an individual or other legal entity; L. "recipient" means a person whom the authority has determined to be eligible to receive medicaid-related services; M. "secretary" means the secretary of health care authority; and N. "subcontractor" means a person that contracts with a medicaid provider or a managed care organization to provide medicaid-related services to recipients.