Home care billing · NM
Home care billing in New Mexico
Short answer
Home care billing in New Mexico splits by program. Personal care, respite and home health for Turquoise Care members are plan benefits, and the BCBSNM manual requires those claims to go through the EVV system rather than straight to the plan.
Developmental Disabilities Waiver respite and customized in-home supports are paid by the Health Care Authority, which must receive a claim within 90 calendar days of the date of service under 8.302.2 NMAC. Since September 30, 2025 for fee-for-service and May 20, 2026 for the plans, an agency may also send visits from its own EVV vendor through the state aggregator. A dedicated Remitwright biller runs both tracks, serving New Mexico agencies remotely. Rules for other states are on the home care billing by state page.
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Key facts for New Mexico home care billing
| Fact | In New Mexico | Source |
|---|---|---|
| Programs that pay | Turquoise Care Agency-Based Community Benefit (ABCB); Turquoise Care Self-Directed Community Benefit (SDCB); Developmental Disabilities Waiver (0173.R08.00); Mi Via ICF/IID Waiver (0448.R04.00); Medically Fragile Waiver (0223.R07.00) | 1 |
| How it is delivered | Managed care and fee-for-service | 3 |
| EVV | Open/hybrid | 4 |
| Medicare home health and hospice | Palmetto GBA, Jurisdiction M | 10 |
Programs that pay for home care in New Mexico1
Turquoise Care Agency-Based Community Benefit (ABCB)
The plan benefit that bundles home and community-based services with personal care for members who meet a nursing facility level of care: adult day health, assisted living, behavior support consultation, community transition, emergency response, employment supports, environmental modifications, home-delivered medically tailored meals, home health aide, nutritional counseling, consumer-directed and consumer-delegated personal care, private duty nursing for adults, nursing respite, respite and skilled maintenance therapy.
What the member gets follows the plan's needs assessment. In the BCBSNM Turquoise Care manual every Community Benefit service except home-delivered medically tailored meals is marked as needing prior authorization, and respite is capped at 300 hours per care plan year (BCBSNM manual, cited below).
Turquoise Care Self-Directed Community Benefit (SDCB)
Home and community-based services that a member at nursing facility level of care directs personally, choosing the workers and setting their pay within SDCB-approved rates, with a Support Broker who writes and monitors the SDCB care plan and budget.
A member can move to SDCB only after 120 days of services under the agency-based benefit. Self-directed workers never bill the plan: their claims go to the Fiscal Management Agency under contract with the state, and no SDCB worker may be paid for more than 40 hours in any seven consecutive days (BCBSNM manual, cited below).
Developmental Disabilities Waiver (0173.R08.00)
Case management, community integrated employment, customized community supports, living supports, respite, customized in-home supports, adult nursing, behavior support consultation, crisis support, assistive technology, environmental modifications, non-medical transportation and therapies for adults, for people of any age with autism, an intellectual disability or a developmental disability who meet an ICF/IID level of care.
Under 8.314.5 NMAC, respite and customized in-home supports providers must record each visit in the approved EVV system, and an outside reviewer, an independent third-party assessor, clinically reviews every requested waiver service (8.314.5 NMAC, cited below).
Mi Via ICF/IID Waiver (0448.R04.00)
The self-directed waiver for people of any age who are medically fragile or have autism, an intellectual disability or a developmental disability and meet an ICF/IID level of care: consultant services, employment supports, home health aide, homemaker and direct support, respite, in-home living supports, private duty nursing for adults, behavior support consultation, emergency response, environmental modifications and transportation.
The same Medicaid.gov factsheet records the Supports Waiver (1726.R00.00) as terminated on September 28, 2025.
Medically Fragile Waiver (0223.R07.00)
Case management, home health aide, private duty nursing, respite, nutritional counseling, skilled therapy for adults, behavior support consultation, specialized therapies, environmental and vehicle modifications and specialized medical equipment and supplies, for medically fragile people of any age who meet an ICF/IID level of care.
How the program is delivered
Both. Turquoise Care, a statewide MCO and MLTSS program under 1115(a) demonstration authority since July 1, 2024, carries home health, state plan personal care, HCBS waiver services, private duty nursing and hospice as plan benefits in the CMS 2024 tables. Enrollment is mandatory for aged, blind or disabled adults and children and for full duals, and voluntary for Native American members.3 The participating plans are Blue Cross Blue Shield of NM, Molina Healthcare, Presbyterian Health Plan and UnitedHealthcare, and Total Community Care, doing business as InnovAge Greater NM PACE, enrolls people 55 and older who need a nursing facility level of care in its service area. The 1915(c) waivers sit outside that plan contract: under the DD Waiver rule the Medical Assistance Division or its claims processing contractor pays waiver providers directly, by electronic funds transfer only (8.314.5 NMAC, cited below).
Electronic visit verification
Open/hybrid. New Mexico launched Fiserv's AuthentiCare as a closed EVV solution, then opened it on September 30, 2025 for fee-for-service and May 20, 2026 for managed care. An agency can stay on AuthentiCare, the state and MCO system, at no cost, or pay for its own third-party EVV vendor, whose visit data reaches the state through the Fiserv aggregator once Conduent has approved the agency's EVV System Declaration and Third Party Attestation forms and testing with Fiserv is done.4 The BCBSNM manual says every PCS, respite and home health claim must be submitted through the EVV system, lets an agency edit caregiver arrival and departure times only with a documented reason, and holds every claim carrying an exemption code for review before payment (BCBSNM manual, cited below). CMS found New Mexico compliant for personal care EVV in a January 4, 2021 letter covering the 1905(a)(24) state plan benefit, 1915(c) waivers and 1115 demonstrations, and Medicaid.gov lists the state compliant for home health care services as of January 1, 2024.
Services under EVV2
- Personal care services under the agency-based and self-directed community benefits, in both the consumer-delegated and consumer-directed models, and EPSDT personal care
- Respite under the agency-based and self-directed community benefits
- Home health services, which the plan manual lists as skilled nursing, home health aide, social worker visits, speech therapy, physical therapy and occupational therapy
Authorizations
Through the member's plan. In the BCBSNM manual the plan offers a health risk assessment or a face-to-face needs assessment (CNA), its care coordinator writes the care plan from that assessment, and nearly every Community Benefit service an agency delivers needs the plan's prior authorization. The EVV system then checks each visit against the services authorized in the member's care plan and reconciles paid claims with those authorizations.2 Care coordination level 1 members get a needs assessment every year and level 2 members every six months, and the latest assessment date anchors the follow-up calendar, so a reassessment can change what the next authorization covers. On the DD Waiver the outside reviewer approves services on clinical justification, and the person-centered individual service plan records what the person receives (8.314.5 NMAC, cited below).
Where the claims go
Turquoise Care claims go to the member's plan. BCBSNM gives a contracted provider 180 calendar days from the date of service, a non-contracted provider one year, and 90 calendar days from the date enrollment was added when a member is enrolled retroactively, and its manual says personal care, respite and home health claims must pass through the EVV system first. A claim BCBSNM returns as a dispute or for more information has to come back within 30 days or risk a timely filing denial once the date of service is past 180 days.2 Self-directed workers bill the state's Fiscal Management Agency, which the plan then reimburses. Fee-for-service claims, such as DD Waiver services, must be received within 90 calendar days of the date of service under 8.302.2.11 NMAC, with receipt set by the transaction control number date; a returned, denied or underpaid claim has 90 days from that action to be resubmitted or adjusted, and a claim filed first with another payer has 90 days from that payer's decision, never more than 210 days from the date of service (8.302.2 NMAC, cited below). The Health Care Authority's Turquoise Claims system replaced Omnicaid and the New Mexico Medicaid Portal on March 23, 2026 (BCBSNM provider news, cited below).
Medicare home health and hospice in New Mexico
Palmetto GBA, the A/B MAC for Jurisdiction M, processes fee-for-service Medicare home health and hospice claims for New Mexico and fifteen other states, among them Texas, Oklahoma and Louisiana; its Part A and Part B work covers North Carolina, South Carolina, Virginia and West Virginia, not New Mexico.10 For Turquoise Care members, home health care and intravenous services carry limits and need prior authorization in the BCBSNM benefit grid, and home health aide visits also appear inside the Community Benefit. Medicaid.gov lists New Mexico compliant with the Cures Act home health EVV requirement as of January 1, 2024, a year after the January 1, 2023 federal deadline (Medicaid.gov EVV pages, cited below).
Common rejections in New Mexico, and the fix
Personal care or home health claim sent to the plan outside EVV
The fixBCBSNM requires PCS, respite and home health claims to come through the EVV system, and short-term exceptions are the only kind it grants. The biller closes each visit in AuthentiCare, or confirms the agency's own vendor has delivered it to the aggregator, before any claim is released, and keeps the visit and the claim on the same service and date.
Visits from a new third-party EVV vendor never reach the state
The fixA third-party vendor can start testing with the Fiserv aggregator only after Conduent approves the agency's EVV System Declaration and Third Party Attestation forms. The biller keeps visits flowing through AuthentiCare until the approval and Fiserv testing are complete, then compares the first weeks of aggregator data with the agency's schedule.
Claim with a manual time edit or exemption code held for review
The fixArrival and departure edits need a documented reason, mass adjustments need BCBSNM contacted first, and every claim with an exemption code is reviewed before payment. The biller limits exemption codes to the short-term cases the manual lists, such as dangerous weather, a sick caregiver, a family emergency or lost infrastructure, and keeps the record that proves each one.
Community Benefit hours billed beyond the care plan authorization
The fixCommunity Benefit services need the plan's prior authorization, and EVV matches each visit to what the care plan authorizes. The biller reconciles delivered hours to the authorization every billing cycle, watches the 300-hour respite cap per care plan year, and asks the care coordinator for an update before the agency goes past it.
Self-directed worker's claim sent to the plan
The fixSDCB claims cannot be submitted to the plan. They go to the Fiscal Management Agency on the state's two-week payroll schedule after the member approves the timesheet, so the biller separates SDCB members from agency-based members on the account and routes each claim accordingly.
DD Waiver claim received after 90 calendar days
The fixUnder 8.302.2.11 NMAC the clock runs from the date of service and receipt is the transaction control number date, not the send date. The biller files waiver claims as visits clear EVV, tracks every claim to a control number, and resubmits returned or denied claims within 90 days of that action.
Plan claim filed after 180 days
The fixA contracted provider has 180 calendar days from the date of service with BCBSNM, and a retroactively enrolled member's claim has 90 days from the date the enrollment was added. The biller ages plan claims from the date of service, checks eligibility for late enrollment adds, and answers returned claims within 30 days.
Remitwright serves New Mexico home care and home health agencies remotely, inside the agency software you already use, with a dedicated biller.
FAQ
Questions from New Mexico agencies
Do we have to keep using AuthentiCare, or can we bring our own EVV system?
Where do we send claims for a Turquoise Care member's personal care visits?
How long do we have to file, plan or state?
Who approves the hours we deliver under the Community Benefit?
A client wants to self-direct. What happens to our billing?
Do DD Waiver services need EVV too?
Which programs pay for home care in New Mexico?
Which services fall under EVV in New Mexico?
Which Medicare contractor pays home health and hospice claims in New Mexico?
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