CASE MANAGEMENT SERVICES PROVIDER IN NEW MEXICO

Fatumata Kaba
Sep 5
4 min read

COORDINATING CARE AND SUPPORT FOR INDIVIDUALS IN HOME AND COMMUNITY SETTINGS

Case Management Services in New Mexico assist individuals with disabilities, chronic conditions, or age-related challenges by coordinating care, advocating for services, and facilitating access to community resources. These services are essential for ensuring that individuals receive comprehensive, person-centered care while maintaining independence. Case Management Services are authorized under New Mexico Medicaid Home and Community-Based Services (HCBS) Waiver programs.

1. GOVERNING AGENCIES

Agency: New Mexico Human Services Department (HSD)

Role: Administers Medicaid waiver funding for Case Management Services and manages provider enrollment, service authorization, and reimbursement.

Agency: Developmental Disabilities Supports Division (DDSD)

Role: Ensures quality standards, service delivery, and compliance for Case Management Services under HCBS waiver programs.

Agency: Centers for Medicare & Medicaid Services (CMS)

Role: Provides federal oversight ensuring Medicaid-funded Case Management Services meet HCBS quality, person-centered planning, and participant protection standards.

2. CASE MANAGEMENT SERVICES OVERVIEW

Case Management Services involve assessment, planning, coordination, and monitoring to ensure that individuals receive appropriate care and support.

Approved providers may deliver:

Comprehensive Assessment: Evaluating individual needs, preferences, and support requirements.
Care Planning: Developing personalized service plans in collaboration with participants and families.
Resource Coordination: Connecting individuals with community services and supports.
Service Monitoring: Tracking the effectiveness of care plans and adjusting as needed.
Crisis Intervention: Providing immediate support during emergencies or changes in health status.
Advocacy: Supporting individual rights and advocating for necessary services.
Referral Services: Linking individuals to healthcare providers, therapists, and social services.
Documentation and Reporting: Maintaining accurate records of care coordination and outcomes.
Care Transitions Support: Assisting with hospital discharges and transitions between care settings.

All services are delivered according to the Individualized Service Plan (ISP) to meet the participant’s unique needs and support goals.

3. LICENSING & PROVIDER APPROVAL REQUIREMENTS

Prerequisites:

Register the business entity with the New Mexico Secretary of State.
Obtain EIN from the IRS and NPI (Type 2).
Enroll as a Medicaid Waiver Case Management provider via the New Mexico Medicaid Provider Enrollment Portal.
Maintain general liability and professional liability insurance.
Develop policies for case management, service coordination, and client advocacy.
Ensure staff meet background checks, health screenings, and case management training requirements.

4. NEW MEXICO PROVIDER ENROLLMENT PROCESS

Initial Interest and Application:

Complete the Provider Enrollment Application through the New Mexico Medicaid Provider Enrollment Portal for Case Management Services under HCBS waivers.

Application and Documentation Submission:

Submit Articles of Incorporation, proof of EIN/NPI, insurance certificates, case management training documentation, and policy manuals.

Program Readiness Review:

HSD and DDSD evaluate provider readiness, including client assessment procedures, documentation standards, and staff qualifications.

Approval & Medicaid Enrollment:

Upon approval, providers are authorized to bill Medicaid for Case Management Services using designated billing codes.

5. REQUIRED DOCUMENTATION

Articles of Incorporation or Business License (New Mexico Secretary of State)
IRS EIN confirmation
NPI confirmation
Proof of general and professional liability insurance
Case Management Services Policy & Procedure Manual, including:
- Intake, assessment, and individualized care planning procedures
- Service coordination, advocacy, and referral guidelines
- Staff credentialing, background checks, and ongoing training records
- Documentation standards for care tracking and Medicaid billing
- HIPAA compliance, participant rights, and grievance handling
- Emergency response, crisis management, and safety protocols
- Quality assurance and compliance monitoring

6. STAFFING REQUIREMENTS

Role: Case Management Program Director

Requirements: Bachelor’s or Master’s degree in social work, human services, or healthcare administration; experience in case management and supervision.

Role: Case Managers

Requirements: Bachelor’s degree in social work, psychology, or a related field; case management certification preferred; experience with client advocacy; background clearance.

Role: Support Coordinators

Requirements: Experience in care coordination and client engagement; basic knowledge of community resources; background clearance.

All staff must complete: