New Mexico Register / Volume XXXVII, Issue 16 / August 25, 2026

TITLE 8 SOCIAL SERVICES

CHAPTER 350 RECONSIDERATION OF UTILIZATION REVIEW

PART 4 RECONSIDERATION OF AUDIT SETTLEMENTS

8.350.4.1 ISSUING AGENCY: New Mexico health care authority (HCA).

[8.350.4.1 NMAC - Rp, 9/1/2026]

8.350.4.2 SCOPE: The rule applies to the general public.

[8.350.4.2 NMAC - Rp, 9/1/2026]

8.350.4.3 STATUTORY AUTHORITY: The New Mexico medicaid program is administered pursuant to regulations promulgated by the federal department of health and human services under Title XIX of the Social Security Act, as amended and by the state health care authority pursuant to state statute. See NMSA 1978 Section 27-2-12 et. seq. (Repl. Pamp. 1991). Section 9-8-1 et seq. NMSA 1978 establishes the health care authority (HCA) as a single, unified department to administer laws and exercise functions relating to health care facility licensure and health care purchasing and regulation.

[8.350.4.3 NMAC - Rp, 9/1/2026]

8.350.4.4 DURATION: Permanent.

[8.350.4.4 NMAC - Rp, 9/1/2026]

8.350.4.5 EFFECTIVE DATE: September 1, 2026, unless a later date is cited at the end of a section.

[8.350.4.5 NMAC - Rp, 9/1/2026]

8.350.4.6 OBJECTIVE: The objective of these regulations is to provide policies for the service portion of the New Mexico medicaid program. These policies describe eligible providers, covered services, noncovered services, utilization review, and provider reimbursement.

[8.350.4.6 NMAC - Rp, 9/1/2026]

8.350.4.7 DEFINITIONS: [RESERVED]

8.350.4.8 MISSION STATEMENT: We ensure that New Mexicans attain their highest level of health by providing whole-person, cost-effective, accessible, and high-quality health care and safety-net services.

[8.350.4.8 NMAC - Rp, 9/1/2026]

8.350.4.9 RECONSIDERATION OF AUDIT SETTLEMENTS:

A. General reconsideration process: Medicaid providers who disagree with an audit settlement can submit a written request for a reconsideration to the New Mexico medical assistance division (MAD) within 30 calendar days of the date on the notice of final settlement. The written request may be submitted by facsimile or by U.S. mail but not by electronic mail. The written request must be received by MAD no later than the thirtieth day from the date of the notice. Filing of a request for reconsideration does not affect the imposition of the final settlement.

(1) Information included in the request: The written request for reconsideration must identify each point on which the provider takes an issue with the audit agent and include all documentation, citations of authority, and arguments on which the request is based. Any point or issue not raised in the original request for reconsideration may not be raised later and will not be considered in the final decision of the reconsideration.

(2) Audit agent response: The written request and supporting materials is forwarded to the audit agent for reconsideration. The audit agent must file a response with MAD within 30 calendar days of the receipt of the request and supporting material from MAD.

(3) Submission of additional material: MAD forwards the audit agent's response to the provider. Additional material from the audit agent or the provider must be received by MAD within 15 calendar days of the date the response was forwarded to the provider. Any additional information, the request for reconsideration and supporting documentation, and the audit agent's response constitute final submittal. The packet containing the final submittal is provided to the MAD deputy director for final submittal by the responsible bureau for program reimbursement.

(4) Decision by MAD: The deputy director may call on all information and call on all expertise they believe is necessary to decide the issue. The deputy director makes a determination and submits a written copy of their findings to each party within 45 calendar days of the date of final submittal to the MAD director. The decision may be sent to the parties by facsimile or U.S. mail. The provider may appeal an adverse decision on the request for reconsideration to the New Mexico health care authority’s hearings bureau pursuant to the 8.353.2 NMAC. The MAD director or designee shall make the decision on the recommendation from the hearing officer.

B. Specific reconsideration process for nursing facility, intermediate care facility for individuals with intellectual disabilities providers: The reconsideration process for audit settlement varies for the aforementioned providers. See 8.312.3 NMAC, Cost Related Reimbursement for Nursing Facilities, and 8.313.3 NMAC, Cost Related Reimbursement of ICF/IID Facilities for specific information.

[8.350.4.9 NMAC - Rp, 9/1/2026]

HISTORY OF 8.350.4 NMAC:

History of Repealed Material: 8.350.4 NMAC - Reconsideration Of Audit Settlements filed 12/16/2002 Repealed effective 9.1.2026.

Other: 8.350.4 NMAC - Reconsideration Of Audit Settlements filed 12/16/2002 Replaced by Reconsideration Of Audit Settlements effective 9/1/2026.