Provider Information
Electronic Data Exchange (EDI)
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What's new with EDI Word Adobe
Adj / Void procedure
EDI Forms Word Adobe
EDI Form Description / usage Word Format Not Available
EDI Provider Trading Partner Agreement Word Format Not Available
EDI Submitter Trading Partner Agreement Word Format Not Available
EDI Authorization Form Word Format Not Available
EDI Update Form Word Format Not Available
EDI Termination Form Word Format Not Available
FAQ's Word Adobe
Provider / Submitter not yet enrolled in EDI Word Format Not Available
Provider / Submitter already enrolled in EDI Word Format Not Available
Link to Companion Guides
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ICD-10 Testing and Provider Information
Topic Word Adobe
ICD-10 FAQs Not Available PDF Format
ICD-10 Testing Through EDI New Mexico Medicaid Not Available PDF Format
ICD-10 Provider Message - New Mexico ICD-10 External End-to-End Testing Not Available PDF Format
ICD-10 Submitter Message - New Mexico ICD-10 External End-to-End Testing Not Available PDF Format
5 Facts about ICD-10 Not Available PDF Format
New Mexico Medicaid ICD-10 Provider Survey # 2
New Mexico Medicaid ICD-10 Submitter Survey # 3
CMS ICD-10 Homepage
ICD-10 Information for Providers
Road to ICD-10
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Important State Announcements
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Topic PowerPoint Adobe
Important Information for Behavioral Health Providers Not Available PDF Format
Medicaid provider audits Not Available PDF Format
Instructions for PCO Claims Submission for Clients In CoLTS Not Available PDF Format
Payment to Providers using Electronic Funds Transfer Not Available PDF Format
PCO Medicaid Payment Reduction effective 12-01-09 Not Available PDF Format
Hospital Provider Payment Reduction effective 12-01-09 Not Available PDF Format
Practitioner Services Medicaid Reduction effective 12-01-09 Not Available PDF Format
RTC Medicaid Payment Reduction effective 12-01-09 Not Available PDF Format
Hospice Provider (Type 362) Rate Changes effective 10/01/2011 Not Available PDF Format
Hospice Provider (Type 362) Rate Changes effective 10/01/2012 Not Available PDF Format
Hospice Provider (Type 362) Rate Changes effective 10/01/2014 Not Available PDF Format
Medicaid Enrollment Review-MAD 220 Form 2013 Not Available PDF Format
EHR Program Basics for Eligible Hospitals 2013 Not Available PDF Format
EHR Program Basics for Eligible Professionals 2013 Not Available PDF Format
Encounter Data Report 2013 Not Available PDF Format
Patient Volume for Eligible Professionals 2013 Not Available PDF Format
MAD 220 Form with 2012 V.1 Instructions Not Available PDF Format
12-13 Dental Supplement : I. Alveoloplasty Coverage II. Authorizations III. Dental Hygienists Scope of Practice IV. Reporting of Rendering Providers Not Available PDF Format
MAD-MR: 12-16 Institutional Care & Home and Community Based Waiver Services Medicaid Appointment Letter MAD 028 Not Available PDF Format
MAD-MR 12-18 2013 Standards in the Institutional Care Medicaid and Home and Community Based Waiver Categories Not Available PDF Format
Notice to Providers on NCCI and Other Topics, October 2014 Not Available PDF Format
NCCI PTP DME Notice Not Available PDF Format
TPA Welcome Letter 03/01/2015 Not Available PDF Format
Important Update on Third-Party Assessor/Utilization Review Activities 04/01/2015 Not Available PDF Format
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Third Party Assessor
The Human Services Department/Medical Assistance Division (HSD/MAD) has awarded the Medicaid Third-Party Assessor (TPA) contract to Qualis Health effective March 1st, 2015.
Programs/services include: Fee For Service Physical and Behavioral Health (including Alternative Benefit Plan); Mi Via waiver; Developmental Disabilities waiver; Medically Fragile waiver; Emergency Services for Undocumented Aliens (EMSA); Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF-IID); and, the Program of All Inclusive Care for the Elderly (PACE).
Quails can be reached at 1-866-962-2180 or http://www.qualishealth.org/patients-families/new-mexico-medicaid
Provider Enrollment
Online Provider Enrollment and MCO-only Provider Registration
Click here to complete your Online Provider Participation Agreement (PPA) MAD 312 and 335 and Electronic Health Record (EHR) MAD220 online. Applications can be submitted for Fee-For-Service(FFS) and Managed Care Organization(MCO) network providers.

The benefits of applying online:
  • Step-by-step fill in the box entry with online edits to prevent common mistakes
  • Easy upload of documents to accompany your application
  • Applications are sent directly and immediately to Xerox Provider Enrollment
Provider Enrollment via Paper Application
Our provider applications have a fresh new look, thanks to federal regulation changes and input collected from the provider community.
Medical Assistance Division revised the Provider Participation Agreement (PPA) MAD 312 and 335. The previous PPA MAD 312 and 335 (revision date of 09/09/03) will no longer be accepted after 05/31/12. Only the new PPAs will be accepted on 06/01/12 going forward and any PPAs on the old forms will be rejected. Providers now have the ability to fill in the PPA, MAD 312 and MAD 335, via computer. Once completed, the PPA must be printed for the applicant's review, initials, and signature (blue ink please!). You may begin using the new PPAs immediately.
Contact NMPRSupport@Xerox.com or Provider Enrollment at 505-246-9988 or 800-299-7304 with any questions about the new PPA.
Please select the applicable New Mexico Provider Enrollment applications from the list below:
PLEASE NOTE: The network for any new Personal Care Service Agencies is closed and HSD/MAD and Xerox will not process any Medicaid applications for this provider type.
Downloading Tips
Topic Word Adobe
MAD 335, Medicaid Provider Participation Agreement for groups or individual billing for own practice Not Available PDF Format
MAD 335 box by box Instructions Word Format PDF Format
MAD 312, Medicaid Provider Participation Agreement to be used for individual applicant within group Not Available PDF Format
MAD 312 box by box Instructions Word Format PDF Format
Provider Type & Specialty Listing Excel Format Not Available
New Mexico Provider Update Form

Word Format Not Available
New Mexico Provider Update Instructions Word Format Not Available
Trading Partner Agreement Form

Not Available PDF Format
New Mexico Medicaid Provider Billing Agent - Submitter Application Not Available PDF Format
AIDS, Developmentally Disabled (DD), & Medically Fragile (MF) Waiver Provider Enrollment Not Available PDF Format
(As part of the enrollment process, you must fill out IRS form W-9. Go to http://www.irs.gov/ to download a copy of the form.)
Personal Care Provider Credentialing Standards
Topic Word Adobe
Consumer-Directed Option Provider Credentialing Standards - 10/04 Word Format PDF Format
Consumer-Delegated Option Provider Credentialing Standards - 10/04: Word Format PDF Format
Training Presentations
Selected Basic, Advanced and Specialty New Mexico Medicaid trainings or PowerPoint presentations are available below to:
  • Learn on your own in the comfort of your home or office at your own pace and time
  • Use as a guide or in a training with your staff
Live Provider Webinar Sessions:
  • Are available at no cost to NM Medicaid Providers
  • Providers are able to attend any session. See 2015 Provider Webinar Schedule for the 2015 webinar schedule
  • No preregistration is required, unless stated for the specific session
  • See the latest New Mexico Medicaid E-News newsletter for registration information
DownloadingTips
Topic PowerPoint Adobe
Web Portal Presentation (Overview) PPT Format PDF Format
Web Registration, Master Adm. & User Presentation PPT Format PDF Format
ADA Dental Online Claims Entry PPT Format PDF Format
Adjustment, Void and Rebill Online Claims Entry PPT Format PDF Format
CMS-1500 Claims Online Entry PPT Format PDF Format
DD Waiver CMS-1500 Online Claims Entry PPT Format PDF Format
UB-04 Online Claims Entry PPT Format PDF Format
Topic PowerPoint Adobe
Tab Run/Cost Audit Reports PPT Format PDF Format
Topic PowerPoint Adobe
Introduction to NM Medicaid PPT Format PDF Format
Reconsideration, Adjustment and Void Workshop PPT Format PDF Format
CMS 1500 Workshop PPT Format PDF Format
Dental Billing Workshop PPT Format PDF Format
UB 04 Workshop PPT Format PDF Format
EMSA Troubleshooting PPT Format PDF Format
Waiver Billing Workshop PPT Format PDF Format
Family Planning PPT Format PDF Format
I.H.S. Tribal/638 Workshop PPT Format PDF Format
Medicaid School-Based Services Provider Training PPT Format PDF Format
Electronic Transactions Workshop PPT Format PDF Format
Required Attachments and Web-Portal Attachment Selections for Claim Submissions Not Available PDF Format
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Forms, Publications, and Instructions
For more information on HSD program policies, refer to: New Mexico Medical Assistance Division Program Policy Manual and Provider Packet Appendix for specific policy manual sections which apply to your specific provider type and specialty.
Adjustments,Voids, and Inquiries
The following publications contain detailed instructions for filling out the Adjustment/Void Request Form (AVR) and the claim inquiry form.
Downloading Tips
Topic PowerPoint Adobe
Reconsideration Request Word Format PDF Format
Adjustment Request Word Format PDF Format
Void Request Word Format PDF Format
Request Form Instructions Word Format PDF Format
HSD/MAD Forms
Topic Word Adobe
MAD 046 Waiver Review Form Not Available PDF Format
MAD 054 Client Information Update Not Available PDF Format
MAD 056 EPSDT Personal Care Service Plan Not Available PDF Format
MAD 301 Home Health Agency Precertification Not Available PDF Format
MAD 302 Eye Services Prior Approval Request-Contact Lenses Not Available PDF Format
MAD 303 Prior Approval Request Not Available PDF Format
MAD 308 Emergency Medical Services for Aliens Referral For Eligibility Determination Not Available PDF Format
MAD 313 Notification of Birth Form Not Available PDF Format
MAD 331 Title XIX Request for Prior Approval Inpatient Rehabilitation Services Not Available PDF Format
MAD 345 Sterilization Consent Form Not Available PDF Format
MAD 378 ICF MR Long Term Care Assessment Abstract Not Available PDF Format
MAD 379 Program of All-Inclusive Care for the Elderly (PACE) Long Term Care Medical Assessment Not Available PDF Format
Instructions in the use of revised MAD-295 - Medicaid Transportation Verification Form & MAD-296 - Medicaid Transportation Form Not Available PDF Format
NM Handicapping Labio-Lingual Deviations, #0000 Not Available PDF Format
MAD 394A Hearing Aid Evaluation Information Not Available PDF Format
Instructions for Filling Out the New Paper Claim Forms
Topic Word Adobe
CMS-1500 Professional Claim Form Not Available PDF Format
UB-04 Institutional Claim Form Not Available PDF Format
ADA 2012 Dental Claim Form Not Available PDF Format
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Presumptive Eligibility Determiner (PED) forms and Training
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Topic Word Adobe
PE MOSAA Portal Registration Workshop Presentation Not Available PDF Format
MAD 008 - Household Size and Income Calculation Worksheet Not Available PDF Format
MAD 011 - Presumptive Eligibility (PE) Applicant Information Form Not Available PDF Format
MAD 070 - Medicaid Presumptive Eligibility Authorization Form Not Available PDF Format
MAD 100 - Medicaid Application for Assistance Not Available PDF Format
MAD 217 - PE/MOSAA Determiner Update Not Available PDF Format
MAD 222 - Federal Poverty Guidelines - Medical Assistance for Men, Women and Children Not Available PDF Format
PE and PE Plus Training Manual Not Available PDF Format
SPANISH FORMS
MAD 011 SP - Formulario de Informacion Para la Solicitud de Probable Eligibilidad (Siglas en Ingles PE) Not Available PDF Format
MAD 100 SP - Solicitud Para Asistencia de Medicaid Not Available PDF Format
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Self-Direction FMA Forms (Mi Via & Self-Directed Community Benefit)
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Topic Word Adobe
Employee Packet Not Available PDF Format
Participant-Employer Demographic Change Form Not Available PDF Format
Affidavit-Statement of Lost or Stolen Check Not Available PDF Format
NM Employee Declaration of Relationship Not Available PDF Format
Declaration of Relationship - Spanish Not Available PDF Format
EIF Employee Information Not Available PDF Format
TNT -DHI Authorization for Release of Information Not Available PDF Format
TNT - I-9 Form Instructions Not Available PDF Format
EA Employee Agreement Not Available PDF Format
TNT - 2010 I-9 Form Not Available PDF Format
TA Employee Transportation Appendix Not Available PDF Format
NM Employee Direct Deposit Authorization Not Available PDF Format
Direct Deposit Authorization - Spanish Not Available PDF Format
Employee 2-Week Mileage Sheet Not Available PDF Format
Timesheet 2-Week Not Available PDF Format
NM Employee Change Form Not Available PDF Format
Form W-4 for Federal Withholding Not Available PDF Format
Form W-4 for Federal Withholding - Spanish Not Available PDF Format
Form W-4 for New Mexico Withholding Not Available PDF Format
Form W-4 for New Mexico Withholding - Spanish Not Available PDF Format
Vendor Form: Vendor Direct Deposit Authorization Not Available PDF Format
Vendor Form: NM Vendor Info Not Available PDF Format
Vendor Form: Payment Request Form Not Available PDF Format
Vendor Form: Form W9 Request for Taxpayer Identification Number - Spanish Not Available PDF Format
Vendor Form: W-9 Form and Instructions 2013 Not Available PDF Format
Vendor Form: Non-Timesheet Invoice Not Available PDF Format
Vendor Form: VA Vendor Agreement Not Available PDF Format
Vendor Form: Vendor Demographic Change Form Not Available PDF Format
Vendor Form: Vendor Mileage Invoice Form Not Available PDF Format
Vendor Form: Vendor Packet Not Available PDF Format
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