Hospital, General Acute Hospital, Rehabilitation Unit in a General … · 2017-08-31 · * Proof of malpractice, professional liability, or medical liability insurance * Federal tax

PROV

TYPE

PROVIDER TYPE AND SPECIALTY DEFINITIONS PROVIDER

SPECIALTY

CODE

REQUIREMENTS

FOR MAD 335 APPLICANTS

USING A FEDERAL EMPLOYER INDENTIFICATION NUMBER (FEIN)

FOR TAX ID PURPOSES (Documentation must be submitted with the PPA)

REQUIREMENTS

FOR MAD 335 APPLICANTS

USING A SOCIAL SECURITY NUMBER (SSN)

FOR TAX ID PURPOSES

(Documentation must be submitted with the PPA)

REQUIREMENTS

FOR

MAD 312 APPLICANTS

(Documentation must be submitted with the PPA)

OPTIONAL DOCUMENTATION/

ADDITIONAL INFORMATION

201 Hospital, General Acute * Copy of Hospital license

* Copy of CLIA certificate

* Fiscal year-end date should be listed in box #31 of MAD 335 form

* Copy of CMS letter verifying Medicare hospital certification or Joint

Commission accreditation letter

* Proof of malpractice, professional liability, or medical liability insurance

* Federal tax identification letter

* Completed W-9 form

N/A N/A DEA certificate

202 Hospital, Rehabilitation Unit in a General

Acute Hospital

* Copy of Hospital license



* PPS exempt units in DRG hospitals need to submit a CMS letter stating that

they meet PPS exemption requirements

* Copy of CMS letter verifying Medicare hospital certification of Joint






203 Hospital, Rehabilitation or Other Specialty * Copy of Specialty Hospital license









204 Hospital, Psychiatric Unit in a General Acute

Hospital

*Copy of Hospital license



* PPS exempt units in DRG hospitals need to submit a CMS letter stating that

they meet PPS exemption requirements


Commission accreditation letter.




N/A N/A N/A

REVISED JUNE 20151

205 Hospital, Psychiatric * Copy of Specialty Hospital license


* Fiscal year-end date should be listed in box # 31 of MAD 335 form


Commission accreditation letter.





211 Nursing Facility, Private * Nursing Facility license issued by the NM DOH




N/A N/A N/A

212 Nursing Facility, State * Nursing Facility license issued by the NM DOH




N/A N/A N/A

213 Hospital, Swing-Bed * Hospital license designating Swing Beds issued by the NM DOH




N/A N/A N/A

214 Intermediate Care Facility for Individuals

with Intelletual Disabilities (ICF IID), Private

* Intermediate Care Facility (ICF) license issued by the NM DOH




N/A N/A N/A

215 Intermediate Care Facility for Individuals

with Intelletual Disabilities (ICF IID), State

Owned

* Intermediate Care Facility (ICF) license issued by the NM DOH




N/A N/A N/A

216 Residential Treatment Ctr, Joint Commission

certified

* Copy of CYFD certification

* Copy of Joint Commission accreditation as a children's RTC





N/A N/A N/A

217 Residential Treatment Center, not Joint

Commission certified

*Copy of CYFD certification





N/A N/A N/A

REVISED JUNE 20152

218 Treatment Foster Care Agency * Copy of CYFD certification




N/A N/A N/A

219 Residential Treatment Center, Group Home,

not Joint Commission certified Group Home






N/A N/A N/A

Hospital or Outpatient Clinic 100 * Copy of I H S certification or Tribal 638 contract

* Fiscal year-end date should be listed in Box #31 of the MAD 335 form



N/A N/A N/A

Dental 102 * Copy of I H S certification or Tribal 638 contract

* Fiscal year-end date should be listed in Box #31 of the MAD 335 form



N/A N/A N/A

301 PHYSICIAN , MD required - see

list below

* City or County Business license




* Copy of Physician license

* Copy of National Board certification

or

Proof of Training or Fellowship in the requested Specialty area (residency

program certification, or letter from chairperson of Residency program stating

that training was received in the Specialty area).






or

Proof of Training or Fellowship in the requested Specialty area, residency


that training was received in the Specialty area.


DEA certificate

**Specialty 001 does not require specialty certification **

**Specialty 143 does not require specialty certification;

however, the provider must also have an additional

specialty**

**Specialty 047 requires Board Certification**

**Specialty 150 requires Self Attestation of meeting AEP

Practitioner Requirements as specified in 8.321.2 NMAC

Section 10 subsection A; and the provider must also have an

additional specialty **

302 PHYSICIAN, DO required - see

list below







or

Proof of Training or Fellowship in the requested Specialty area (residency


that training was received in the Specialty area).






or

Proof of Training or Fellowship in the requested Specialty area, residency


that training was received in the Specialty area.


DEA certificate

**Specialty 001 does not require specialty certification **

**Specialty 143 does not require specialty certification;

however, the provider must also have an additional

specialty**

**Specialty 047 requires Board Certification**

**Specialty 150 requires Self Attestation of meeting AEP

Practitioner Requirements as specified in 8.321.2 NMAC

Section 10 subsection A; and the provider must also have an

additional specialty **

General Practice 001

General Surgery or Other Specialized Surgery

not otherwise listed

002

Allergy 003

ENT (Ear, Nose, Throat) 004

Anesthesiology 005

Cardiology 006

Dermatology 007

Indian Health Services or Tribal 638 Contract Facility

Specialties for types 301 & 302

221

REVISED JUNE 20153

Family Practice 008

Gastroenterology 010

Hematology or Oncology 011

Manipulative Therapy 012

Neurology 013

Neurological Surgery 014

Obstetrics 015

OB-GYN 016

EENT (Eye, Ear, Nose, Throat) 017

Ophthalmology 018

Neonatology 019

Orthopedic Surgery 020

Emergency Medicine 021

Pathology 022

Peripheral Vascular Disease 023

Plastic Surgery 024

Physical Medicine & Rehabilitation 025

Psychiatry, Other 026

Pain Management 027

Proctology 028

Pulmonary Disease 029

Radiology 030

Radiation Therapy 032

Thoracic Surgery 033

Urology 034

Nuclear Medicine 036

Pediatrics 037

Geriatrics 038

Nephrology 039

Hand Surgery 040

Internal Medicine 041

Cardiology, Pediatric 042

Allergy, Pediatric 043

Public Health 044

Preventative Medicine 046

Psychiatry, Board Certified, Child/Adolescent 047

Endocrinology/Diabetes/Metabolism 048

Multiple Specialties

(applicable only to a group)

049

Addictionologist 050

Cardiac or Peripheral Vascular Surgery 140

Critical Care 141

Genetic Counseling 142

Hospitalist 143

Oral & Maxillofacial Surgery 144

Rheumatology 145

Sleep Medicine 146

Sports Medicine 147

Transplant Surgery 148

Autism Evaluation Provider

(not applicable to a group)

150

303 Physician Component for Hospital, Nursing

Facility, or Other Residential Provider

049 * City or County Business license




N/A N/A N/A

305 Physician Assistant N/A N/A * Copy of Physician Assistant license

* Copy of certificate from the National Commission on certification of Physician

Assistants (NCCPA)


**** For I.H.S. or Tribal 638 contract providers, a copy of the certificate from the

NCCPA is required. A license is not required. ****

N/A

REVISED JUNE 20154

306 Clinical Nurse Specialist, Medical * City or County Business license




* Copy of CLINICAL NURSE SPECIALIST license

or

RN license designating CNS certification

*Copy of National Board Certification




* Copy of CLINICAL NURSE SPECIALIST license

or

RN license designating CNS certification

* Copy of National Board Certification


DEA certificate

311 Clinic, Non-profit Treatment & Diagnostic

Center

*Copy of Diagnostic & Treatment Center license





N/A N/A N/A

312 Clinic, Family Planning *Copy of Diagnostic & Treatment Center license





N/A N/A N/A

313 Clinic Federally Qualified Health Center * Copy of letter from CMS certifying the center as an FQHC

* Fiscal Year-End date should be listed in Box #31 of the MAD 335 form




N/A N/A N/A

314 Clinic, Rural Health Medical, freestanding * Copy of CMS letter certifying clinic as a Rural Health Clinic

* Copy of Rural Health Clinic license

* Copy of Medicare letter setting reimbursement rate





N/A N/A N/A

315 Clinic, Rural Health Medical, hospital based * Copy of CMS letter certifying Clinic as a Rural Health Clinic

* Copy of Rural Health Clinic license





N/A N/A N/A

Nurse, Certified Nurse Practitioner (CNP) 316

REVISED JUNE 20155

General 090 * City or County Business license




* Copy of Certified Nurse Practitioner license

or

A copy of the RN license designating Nurse Practitioner certification






or




DEA certificate

Family Practice 091 * City or County Business license





or







or




DEA certificate

Pediatrics 092 * City or County Business license





or







or




DEA certificate

Obstetrical 093 * City or County Business license





or







or




DEA certificate

Psychiatric 097 * City or County Business license





or







or




DEA certificate

Psychiatric RN 059 N/A N/A * Copy of Registered Nurse license



**Psychiatric Nurses can only be affiliated to provider types:

221-Indian Health Services/Tribal 638, 301 & 302 -Physician

(MD or DO) groups, 311-Licensed Diagnostic Treatment

Center, 312-Family Planning Clinic, 313-Federally Qualified

Health Centers, 314 & 315 -Rural Health Clinics, 324-Private

Duty Nursing Agency, 432-Behavioral Health Agency, 433-

Community Mental Health Center, and 446-Core Service

Agency**

Nurse, RN

316

317

REVISED JUNE 20156

School Nurse 094 N/A N/A * Copy of Registered Nurse license

* Copy of PED license


**School Nurses can only be affiliated to provider type 345-

School**

EPSDT Screening Nurse 095 N/A N/A * Copy of Registered Nurse license


**EPSDT Screening Nurses can only be affiliated to provider

types: 221-Indian Health Services/Tribal 638, 301 & 302 -

Physician (MD or DO) groups, 311-Licensed Diagnostic

Treatment Center, 312-Family Planning Clinic, 313-Federally

Qualified Health Centers, 314 & 315 -Rural Health Clinics, and

321-School Based Health Center**

Other RN or LPN 096 N/A N/A * Copy of Registered Nurse license or LPN license


**Psychiatric Nurses can only be affiliated to provider types:

221-Indian Health Services/Tribal 638, 301 & 302 -Physician

(MD or DO) groups, 311-Licensed Diagnostic Treatment

Center, 312-Family Planning Clinic, 313-Federally Qualified

Health Centers, 314 & 315 -Rural Health Clinics, 324-Private

Duty Nursing Agency, 432-Behavioral Health Agency, 433-

Community Mental Health Center, and 446-Core Service

Agency**

318 Nurse, CRNA * City or County Business license




* Copy of CRNA license

or

A copy of the RN license designating Nurse Anesthetist certification




* Copy of CRNA license

or

A copy of the RN license designating Nurse Anesthetist certification


N/A

319 Anesthesiologist Assistant * City or County Business license




* Copy of Anesthesiologist Assistant license

* Copy of certification from the National Commission on the certification of

Anesthesiologist Assistants (NCCAA)




* Copy of Anesthesiologist Assistant license

* Copy of certification from the National Commission on the certification of

Anesthesiologist Assistants (NCCAA)


N/A

320 Pharmacist Clinician N/A N/A * Copy of Pharmacist Clinician license


**** National Clinical Pharmacy Specialist (NCPS) Certifcation plus a copy of the

State license (other than NM) can be accepted on Pharmacist Clinicians affiliating

with I.H.S. or Tribal 638 providers.****

N/A

321 School Based Health Center (Non-FQHC)

(NOTE: if site is certified as an FQHC, must

enroll as provider type 313-FQHC)

* Copy of HSD/MAD School Health Office certification (or exemption) as a School

Based Health Center




N/A N/A N/A

322 Midwife, Certified Nurse * City or County Business license




* Copy Certified Nurse Midwife license

or

A copy of the RN license designating Certified Nurse Midwife




* Copy Certified Nurse Midwife license

or

A copy of the RN license designating Certified Nurse Midwife


* To participate in the Birthing Options Program, Midwives

must complete the supplemental agreement & affidavit

available on the HSD/MAD website.

317

REVISED JUNE 20157

323 Midwife, Licensed (Non-Nurse) * City or County Business license


* Birthing Options Program Affidavit of Insurance

* Birthing Options Program Supplemental Agreement


* Copy of Midwife license





* Copy of Midwife license



* To participate in the Birthing Options Program, Midwives

must complete the supplemental agreement & affidavit

available on the HSD/MAD website.

324 Nursing Agency, Private Duty * Copy of Home Health Agency license

or

* Copy of letter from CMS showing certification as an FQHC





N/A N/A * Agencies not providing "medically directed" services are not

required to have a Home Health Agency license or FQHC

certification. Provider should instead include written

statement that no medically directed services are rendered.

325 Podiatrist * City or County Business license




* Copy of Podiatry license




* Copy of Podiatry license


N/A

331 Audiologist * City or County Business license




* Copy of Audiologist license




* Copy of Audiologist license


N/A

333 Dietician/Nutritionist N/A N/A * Copy of Dietician or Nutritionist license


N/A

334 Optician * City or County Business license







N/A N/A

335 Optometrist * City or County Business license




* Copy of Optometrist license




* Copy of Optometrist license


N/A

REVISED JUNE 20158

336 Orthotist * City or County Business license







* Copy of Orthotist license


N/A

337 Prosthetist * City or County Business license







* Copy of Prosthetist license


N/A

338 Prosthetist & Orthotist * City or County Business license







* Copy of Prosthetist/Orthotist license


N/A

341 Chiropractor * City or County Business license




* Copy of Chiropractor license

* CMS letter showing Medicare number




* Copy of Chiropractor license

* CMS letter showing Medicare number


N/A

343 Methadone Clinic 1. DEA Certification to operate an Opioid Treatment Program (OTP)

2. Copy of Substance Abuse & Mental Health Services Administration/Center for

Substance Abuse Treatment (SAMHSA/CSAT) approval to operate an OTP

3. Copy of accreditation by the Joint Commission

or

A copy of the Commission on Accreditation of Rehabilitation Facilities (CARF)

accreditation

4. Approval letter from Behavioral Health Services Division (BHSD) as a

Methadone provider





N/A N/A N/A

Developmentally Disabled Waiver 070 * Copy of program approval letter from DOH DDSD or CoLTS program





* Copy of program approval letter from DOH DDSD program




N/A N/A

Home & Community Based Services (Waiver)344

REVISED JUNE 20159

Medically Fragile Waiver 073 * Copy of program approval letter from DOH DDSD or CoLTS program









N/A N/A

DD Waiver Case Management 074 * Copy of program approval letter from DOH DDSD or CoLTS program









N/A N/A

Medically Fragile Waiver

Case Management

077 * Copy of program approval letter from DOH DDSD or CoLTS program









N/A N/A

345 Schools * Letter of Intent

* Signed Agreement between the Human Services Dept and the School



N/A N/A N/A

346 Lodging, Meals * City or County Business license




N/A N/A N/A

351 Lab, Clinical Freestanding * Copy of CLIA certification applicable to the category of procedures performed

by the Laboratory




N/A N/A N/A

352 Radiology Facility * City or County Business license

* DOH license if mobile/portable * Proof of

malpractice, professional liability, or medical liability insurance



N/A N/A N/A

344

REVISED JUNE 201510

353 Laboratory, Clinical with Radiology * Copy of CLIA certification applicable to the category of procedures performed

by the Laboratory




N/A N/A N/A

354 Laboratory, Physiological (Diagnostic &

Testing, Physical Measurements)





N/A N/A N/A

361 Home Health Agency * Copy of Home Health Agency license

* Copy of CMS letter verifying Medicare certification

* Fiscal Year-End date should be listed in Box # 31 of the MAD 335 form





N/A N/A N/A

362 Hospice * Copy of Hospice license

* Copy of CMS letter verifying Medicare certification

* Fiscal Year-End date should be listed in Box # 31 of the MAD 335 form





N/A N/A N/A

363 Community Benefit Provider-MCO Only * Copy of MAD Program Approval letter




* Copy of MAD Program Approval letter




N/A N/A

364 Ambulatory Surgical Center * Copy of Ambulatory Surgical Center license

* Letter from CMS certifying Center to participate in Medicare as a Free-standing

Ambulatory Surgical Center




N/A N/A N/A

401 Ambulance, Air * Copy of Air Ambulance license




N/A N/A N/A

REVISED JUNE 201511

402 Ambulance, Ground * City or County Business license




******** NM applicants must also submit:

1. Copy of Tariff from the Public Regulation Commission

2. Certificate of Convenience and Necessity from the Public Regulation

Commission

******* Out of State applicants must also submit:

1. Documentation of their Usual & Customary rates (rate table).

N/A N/A N/A

403 Handivan *NM PUBLIC REGULATION COMMISSION (PRC) certification for Non Emergency

Medical Transportation





N/A N/A N/A

404 Taxi or MCO General Transportation

Contractor (non-capitated)

*NM PUBLIC REGULATION COMMISSION (PRC) certification for Non Emergency

Medical Transportation





N/A N/A N/A

412 Hearing Aid Supplier * Copy of Hearing Aid Dispenser license





* Copy of Hearing Aid Dispenser license




N/A N/A

414 Medical Supply Company * City or County Business license




*** Out of State providers must also submit:

* Copy of Medicare certification as a DMEPOS provider.

N/A N/A N/A

415 IV Infusion Services * City or County Business license




N/A N/A N/A

416 Pharmacy

REVISED JUNE 201512

In-State Pharmacy * Copy of NM Pharmacy license

* Copy of DEA certificate

* NCPDP # must be listed in Box #28 of the MAD 335 form




* Completed W-9 for

N/A N/A N/A

I.H.S. or Tribal 638 Pharmacy * Copy of DEA certificate




N/A N/A N/A

Out-of-State Pharmacy * Copy of Home-state Pharmacy license

* Copy of a New Mexico Non-Residential Pharmacy license must also be

submitted by pharmacies located outside of New Mexico that ship, mail, or

deliver in any manner, prescription drugs to New Mexico patients or consumers.

* Copy of DEA certificate

* NCPDP # must be listed in Box #28 of the MAD 335 form.





N/A N/A N/A

417 Pharmacy, Rural Health Clinic * Copy of Pharmacy license





N/A N/A N/A

General Dentistry 055 * City or County Business license




* Copy of current Dental license






DEA certificate

416

421 Dentist

REVISED JUNE 201513

Oral Surgery, Endodontics, Other Specialty 056 * City or County Business license






or

Proof of training or Fellowship in specialty area, residency program certification,

or letter from chairperson of residency program.






or

Proof of training or Fellowship in specialty area, residency program certification,

or letter from chairperson of residency program.


DEA certificate

Certified for Behavior Management 057 * City or County Business license





* DOH certification for Behavioral Management





* DOH certification for Behavioral Management


DEA certificate

422 Dental Clinic, Rural Health * Copy of CMS letter certifying clinic as a Rural Health Clinic




N/A N/A N/A

423 Dental Hygienist * City or County Business license




* Copy of Dental Hygienist license




* Copy of Collaborative Practice Dental Hygienist certification

* Copy of Collaborative Practice agreement(s) between the Dental Hygienist &

each consulting Dentist, signed & dated by both the Dental Hygienist & Dentist.

* List of consulting Dentist(s), to include Dentist's names, addresses, telephone

numbers, and NM Medicaid provider numbers. An updated list must be

submitted to NM Medicaid when changes occur.

* Copy of Dental Hygienist license


* Copy of Collaborative Practice Dental Hygienist certification

* Copy of Collaborative Practice agreement(s) between the Dental Hygienist &

each consulting Dentist, signed & dated by both the Dental Hygienist & Dentist.

* List of consulting Dentist(s), to include Dentist's names, addresses, telephone

numbers, and NM Medicaid provider numbers. An updated list must be

submitted to NM Medicaid when changes occur.

N/A

Behavior Technician 098 N/A N/A * Employing agency attestation of meeting BT requirements in 8.321.2 NMAC

section 10 subsection A


**Behavior Technicians can only be affiliated with agencies or

facilities certified for ABA (specialty 132)**

Behavioral Management Service (BMS)

Worker

113 N/A N/A * Proof of malpractice, professional liability, or medical liability insurance **BMS Workers can only be affiliated with agencies or

facilities certified for BMS (specialty 081)**

Peer Specialist/Worker, Certified 114 N/A N/A * Copy of professional certification


**Certified Peer Specialists can only be affiliated with

agencies or facilities certified for CCSS (specialty 107)**

Family Specialist, Certified 115 N/A N/A * Copy of professional certification


**Certified Family Specialists can only be affiliated with


Behavioral Health Worker430

421

REVISED JUNE 201514

Community Support Worker 116 N/A N/A * Employing agency attestation of meeting CSW requirements in 8.321.2 NMAC



**Community Support Workers can only be affiliated with


Not Certified for Prescribing 111 * City or County Business license




* Copy Clinical Psychologist license

* DEA Certificate






N/A

Certified for Prescribing 112 * City or County Business license





* DEA Certificate





* DEA Certificate


N/A

Autism Evaluation Provider

(not applicable to a group)

150 N/A * Copy Clinical Psychologist license

* Self Attestation of AEP Practitioner Requirements as specified in 8.321.2 NMAC

Section 10 subsection A





* Self Attestation of meeting AEP Practitioner Requirements as specified in

8.321.2 NMAC Section 10 subsection A


** Specialty 150 providers must also have an additional

specialty**

Behavioral Management Services 081 * City or County Business license

* Copy of CYFD certification for BMS




N/A N/A N/A

Day Treatment Services 082 * City or County Business license

* Copy of CYFD certification for Day Treatment




N/A N/A N/A

Intensive Out Patient (IOP) 108 * City or County Business license

* Copy of MAD letter allowing IOP services




N/A N/A N/A

Behavioral Health Agency

430

431

432

Psychologist, (Ph.D., Ed.D., Psy.D.)

REVISED JUNE 201515

Assertive Community Treatment (ACT) 130 * City or County Business license

* Copy of MAD letter allowing ACT services




N/A N/A N/A

Multi-Systemic Therapy (MST) 131 * City or County Business license

* Copy of MST Inc license




N/A N/A N/A

Autism Disorder ABA Services 132 * City or County Business license

* Copy of MAD letter allowing ABA services




N/A N/A N/A

Evaluation and Therapies 133 * City or County Business license

* MAD 312's for affiliating Independent Practitioners must accompany the MAD

335 form




N/A N/A N/A

Adult Psychological Rehabilitation Services 080 * City or County Business license

* Copy of DOH license as a Community Mental Health Center




N/A N/A N/A



* Copy of CYFD certification for BMS




N/A N/A N/A



* Copy of CYFD certification for Day Treatment




N/A N/A N/A

Clinic, Mental Health Center - DOH Certified (CMHC)

432

433

REVISED JUNE 201516

Comprehensive Community Support Service 107 * City or County Business license


*Copy of CYFD

or

DOH certification




N/A N/A N/A

Intensive Out Patient 108 * City or County Business license






N/A N/A N/A







N/A N/A N/A







N/A N/A N/A







N/A N/A N/A




335 form




N/A N/A N/A

433

REVISED JUNE 201517

435 LPCC

Licensed Professional Clinical Counselor





* Copy of LPCC license




* Copy of LPCC license


N/A

436 LMFT

Licensed Marriage & Family Therapist





* Copy of LMFT license




* Copy of LMFT license


N/A

438 Psychologist School Certified N/A N/A * Copy of (PED) School Psychologist license **School Psychologists can only be affiliated with School

providers (345)**

LADAC

Licensed Alcohol & Drug Abuse Counselor

124 N/A N/A * Copy of LADAC license


*****LADACs can only be affiliated with provider types: 432-

Behavioral Health Agency, 433-Community Mental Health

Center, 313-Federally Qualified Health Center, 221-Indian

Health Services/Tribal 638, 345-School, and 446-Core Service

Agency*****

LSAA

Licensed Substance Abuse Associate

(under supervision)

125 N/A N/A * Copy of LSAA license


*****LSAAs can only be affiliated with provider types: 432-

Behavioral Health Agency, 433-Community Mental Health

Center, 313-Federally Qualified Health Center, 221-Indian

Health Services/Tribal 638, 345-School, and 446-Core Service

Agency*****

Case Management-Developmentally

Disabled Children


* Copy of CYFD or DOH certification



N/A N/A N/A

Case Management-Developmentally

Disabled Adults


* Copy of DOH certification



N/A N/A N/A

Early Intervention Services 083 * City or County Business license

* Copy of provider certification letter from the Early Childhood Coordinator,

Family Infant Toddler Program, DOH




N/A N/A N/A






N/A N/A N/A

Substance Abuse Counselor

Developmental Delay Service (Do Not Use for Behavioral

Health)

440

441

REVISED JUNE 201518

443 Psychiatric Clinical Nurse Specialist * City or County Business license




* Copy of Clinical Nurse Specialist license

or

A copy of the RN license designating Clinical Nurse Specialist certification





* Copy of Clinical Nurse Specialist license

or

A copy of the RN license designating Clinical Nurse Specialist certification


DEA certificate

444 Social Worker, LCSW

(Licensed Clinical Social Worker)





* Copy of LCSW license

* Copy of PED license if affiliating with a Public School




* Copy of LCSW license



N/A

LAMFT

Licensed Associate Marriage and Family

Therapist (under supervision)

058 N/A N/A * Copy of LAMFT license


Master's Level Psychologist (under

supervision)

086 N/A N/A * Copy of Master's level diploma in psychology


LMSW

Licensed Master's Level Social Worker (under

supervision)

087 N/A N/A * Copy of LMSW license


Psychologist Associate (under supervision) 088 N/A N/A * Copy of Psychologist Associate license


MA

Master of Arts (psychology related) (under

supervision)

089 N/A N/A * Copy of Master's level diploma in a clinically related field


Behavior Analyst 099 N/A N/A * Employing agency attestation of meeting BA requirements in 8.321.2 NMAC



**Behavior Analysts can only be affiliated with agencies or

facilities certified for ABA services (specialty 132)**

LBSW

Licensed Baccalaureate Social Worker (under

supervision)

119 N/A N/A * Copy of LBSW license


N/A

LMHC

Licensed Mental Health Counselor (under

supervision)

122 N/A N/A * Copy of Mental Health Counselor (LMHC) license


N/A

LPAT

Licensed Professional Art Therapist

123 N/A N/A * Copy of Professional Art Therapist (LPAT) license


N/A

Nurse Practitioner (Advanced Practice Nurse)

(under supervision)

126 N/A N/A * Copy of Graduate Nurse Practitioner license


N/A

446

Counselors, Therapists, and other Social Workers

Core Service Agency

445

REVISED JUNE 201519

Adult Psychological Rehabilitation Services 080 * City or County Business license


* Copy of MAD or BH Collaborative letter of approval as a CSA.




N/A N/A N/A







N/A N/A N/A







N/A N/A N/A

Comprehensive Community Support Service 107 * City or County Business license



or

DOH certification




N/A N/A N/A

Intensive Out Patient 108 * City or County Business license






N/A N/A N/A







N/A N/A N/A

446

REVISED JUNE 201520







N/A N/A N/A







N/A N/A N/A




335 form




N/A N/A N/A

447 Renal Dialysis Facility * Copy Renal Dialysis facility license

* Copy of Medicare letter from CMS certifying facility as a Renal Dialysis Facility

* Fiscal Year-end date should be listed in Box #31 of the MAD 335 form




N/A N/A N/A

451 Occupational Therapist, Licensed & Certified * City or County Business license




* Copy of Occupational Therapist license

* Copy of Medicare certification









N/A

452 Occupational Therapist, Licensed, Not

Certified













N/A

446

REVISED JUNE 201521

453 Physical Therapist, Licensed & Certified * City or County Business license




* Copy of Physical Therapist license










N/A

454 Physical Therapist, Licensed, Not Certified * City or County Business license












N/A

455 Rehabilitation Facility, Comprehensive

Outpatient (CORF)

* Copy of DOH license as either a "Limited Diagnostic & Treatment Center"

or

"Comprehensive Outpatient Rehabilitation Facility"

* Copy of Medicare letter certifying Center as a Rehabilitation Center




N/A N/A N/A

457 Speech Therapist, Licensed * City or County Business license




* Copy of Speech Therapist license





* Copy of Speech Therapist license



N/A

458 Speech Therapist for Children, School

Certified

N/A N/A * Copy of Speech Therapist License

* Copy of PED license (not required for Clinical Fellows, but is required upon

license upgrade)

N/A

Case Management

Medically at risk (EPSDT) children

061 * Copy of letter, on agency letterhead, stating they are a Government or

Community Agency, an IHS/Tribal 638 service, or FQHC





N/A N/A N/A

Case Management

Developmentally Disabled Children

062 * Copy of DOH or CYFD certification





N/A N/A N/A

462 Case Management Agency or Case Manager

REVISED JUNE 201522

Case Management

Developmentally Disabled Adults

063 * Copy of DOH certification





N/A N/A N/A

Case Management

Maternal and Child Care (Families First)

064 * Copy of DOH certification

* Copy of Families First letter of certification





N/A N/A N/A

Case Management

Traumatic Brain Injury

065 * Copy of letter, on agency letterhead, stating provider is a Government or

Community Agency, an IHS/Tribal 638 service, or FQHC





N/A N/A N/A

901 Accupuncturist, Licensed, or Doctor of Oriental

Medicine





* Copy of Professional license






902 Dental Clinic, FQHC * Copy of letter from CMS certifying the center as an FQHC




N/A N/A

904 Physical Health Enhanced Service or Enhanced

Service Provider





* Written description of services being delivered

* Copy of Professional license (if applicable)








906 Speech Therapist, Not Certified N/A * Copy of Professional license








462

REVISED JUNE 201523

922 Behavioral Health Enhanced Service or Enhanced

Service Provider


* Copy of facility license (if applicable)













923 Promotora or Other Traditional Healers * City or County Business license











REVISED JUNE 201524

Documents

Hospital, General Acute Hospital, Rehabilitation Unit in a General … · 2017-08-31 · * Proof of malpractice, professional liability, or medical liability insurance * Federal tax