New Mexico - Case Management Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

The New Mexico Health Care Authority (HCA) Developmental Disabilities Supports Division (DDSD) oversees the approval of Case Management agencies for the Developmental Disabilities (DD), Medically Fragile (MFW), and Supports Waivers. Prospective agencies must secure a Provider Agreement through the Provider Enrollment Relations Unit (PERU) and demonstrate full compliance with the CMS HCBS Final Rule settings requirements before any waiver provider application is approved.

Agencies must submit an annual business license for each operating county to the YES.NM portal to maintain their Medicaid number. For specialized populations, such as the Medically Fragile Waiver, the state restricts case management delivery to agencies employing New Mexico-licensed Registered Nurses (RNs) with at least two years of specific pediatric or critical care experience, and the Department of Health (DOH) exercises discretion to contract based on geographic network adequacy.

1. Service Definition and Scope

In New Mexico, Case Management services under the DD, Medically Fragile, and Supports Waivers are designed to assist eligible children and adults with Intellectual and Developmental Disabilities (IDD) or medical fragility in gaining access to needed waiver and other State Plan services. The service encompasses assessment, person-centered Individual Service Plan (ISP) development, referral, and continuous monitoring of the participant's health, safety, and welfare.

Case managers act as the primary coordinators across the participant's full service package, ensuring that services complement unpaid supports. They are responsible for facilitating the Primary Freedom of Choice (PFOC) process and monitoring the implementation of the ISP through regular contacts and reviews.

• Target Population: Individuals allocated to the Developmental Disabilities (DD) Waiver, Medically Fragile Waiver (MFW), or Supports Waiver.
• Core Function: Individual Service Plan (ISP) development and ongoing monitoring.
• Service Delivery Model: Agency-based delivery requiring a Provider Agreement with the HCA.
• Waiver Assurance Domains: Level of care, service plans, qualified providers, and health, safety, and welfare.

2. Regulatory and Oversight Agencies

The New Mexico Health Care Authority (HCA) serves as the Single State Agency administering the Medicaid program. Within the HCA, the Developmental Disabilities Supports Division (DDSD) directly manages the waiver programs and sets provider standards.

Provider enrollment and agreement maintenance are handled by the Provider Enrollment Relations Unit (PERU), while the Quality Management Bureau (QMB) conducts regulatory oversight and unannounced compliance surveys of approved case management agencies.

• New Mexico Health Care Authority (HCA): Administers the Medicaid State Plan and waivers (https://www.hca.nm.gov/).
• Developmental Disabilities Supports Division (DDSD): Manages waiver operations and provider standards (https://www.hca.nm.gov/developmental-disabilities-supports-division).
• Provider Enrollment Relations Unit (PERU): Processes DDSD provider agreements and maintains credential records (https://www.hca.nm.gov/provider-enrollment-relations).
• Quality Management Bureau (QMB): Conducts unannounced surveys and enforces Conditions of Participation (COPs) (https://www.hca.nm.gov/ddw-case-management-services).

3. Gatekeeping Prerequisites: Who Can Even Apply

New Mexico imposes strict structural prerequisites before a case management application is accepted. Most notably, new provider agencies must prove compliance with the CMS HCBS Final Rule settings requirements within their application policies before PERU will approve them to provide waiver services.

For the Medically Fragile Waiver (MFW), the state utilizes geographic need-based contracting. The DOH/DDSD evaluates the availability of qualified Case Management Agencies within specific geographic areas or DDSD Regions. If a lack of qualified agencies exists, the state may exercise discretion to contract with licensed Medicaid Home Health Agencies that employ qualified RNs to fulfill the case management coordination role.

• HCBS Settings Compliance: Must be demonstrated and approved prior to waiver provider enrollment.
• Geographic Network Need (MFW): DOH contracts for case management services based on regional need and lack of qualified agencies.
• Business License Prerequisite: Must obtain and submit a local business license for every county/city of operation prior to Medicaid enrollment.
• Liability and Bond Insurance: Required as a precondition for all DDSD waiver provider applications.

4. Licensure and Certification Requirements

New Mexico does not issue a standalone "Case Management License" at the state facility level. Instead, agencies must maintain active local business licenses for every jurisdiction in which they operate and achieve compliance with the DDSD Accreditation Policy.

Agencies must submit their business licenses annually to the YES.NM portal. Failure to maintain and submit these local licenses results in the termination of the agency's Medicaid provider number.

• Local Business License: Required for each county/city where services are provided, submitted annually.
• DDSD Accreditation Policy: Case Management Agencies must maintain current provider status and comply with DDSD accreditation standards.
• Professional Licensure: The agency must ensure all individual case managers hold the required professional licenses (e.g., RN for MFW) and submit these to PERU annually.
• Subcontractor Documentation: Agencies utilizing subcontractors must submit their licenses and education requirements to PERU upon hire.

5. Medicaid Provider Enrollment

Agencies seeking to bill Medicaid for case management must enroll through the YES.NM portal. The enrollment process requires submitting the DDSD Provider Agreement, proof of local business licenses, and agency policies.

Effective October 1, 2026, the HCA mandates that all attending, referring, ordering, and prescribing providers must be fully enrolled with Medicaid, or claims will be denied. Providers must ensure their applications are processed by this deadline.

• Enrollment Portal: YES.NM website (https://yes.nm.gov).
• Provider Agreement: Must be established with the Provider Enrollment Relations Unit (PERU).
• Enrollment Deadline: October 1, 2026, for all ordering, referring, and prescribing providers to avoid claim denials.
• Required Identifiers: National Provider Identifier (NPI) and Tax Identification Number (TIN) must be registered.

6. Staffing, Training and Background Checks

Staffing qualifications vary significantly by waiver. For the Medically Fragile Waiver (MFW), case managers must meet stringent clinical requirements, reflecting the complex medical needs of the target population.

Agencies must maintain resumes, education records, and active licenses for all case managers and community supports coordinators, submitting updates to PERU whenever a new staff member or subcontractor is hired.

• MFW Case Manager Credential: Must be a licensed Registered Nurse (RN) in the State of New Mexico.
• MFW Experience Requirement: Minimum of two (2) years of experience with the target population in pediatrics, critical care, or public health.
• Specific Setting Experience: At least one (1) year of the required experience must be in a home health program, hospital, or long-term care program.
• Knowledge Areas: Must demonstrate knowledge in human growth, disease processes, and accessing community resources.

7. Documentation, Policies and Records

Case Management Agencies must develop and implement comprehensive written policies that protect the physical and mental health of participants and comply with all DDSD policies and New Mexico State statutes.

Agencies are required to maintain a Continuous Quality Improvement Plan and submit specific organizational documentation to PERU annually, including an updated Board of Directors roster.

• Continuous Quality Improvement Plan: Must be updated and implemented annually; summary submitted to PERU upon request or during audits.
• Board of Directors Roster: Must be submitted annually to PERU (including names, addresses, phone numbers, and emails).
• Annual Report: Submitted via web links provided by PERU at least four months prior to February 15th.
• Policy Requirements: Must include written procedures addressing HCBS settings requirements and participant health and safety.

8. Billing, Rates and Claims

Case management services are billed to the New Mexico Medicaid program using the agency's NPI and TIN. Claims must be submitted in accordance with HCA guidelines to ensure timely reimbursement.

Providers must use the correct Payer ID when submitting claims and ensure that all rendering and referring providers are actively enrolled in the YES.NM system to prevent administrative denials.

• Payer ID: 87748 for standard Medicaid claims (87726 for electronic visit verification claims).
• Claim Requirements: Must include NPI and Tax Identification Number (TIN).
• Denial Trigger: Claims with dates of service on or after October 1, 2026, will be denied if the referring/ordering provider is not enrolled.
• Budget Limits: Supports Waiver services are capped at a $10,000 annual budget per participant, which the case manager helps monitor.

9. Approval Sequence and Timeline

The approval sequence begins with the submission of the DDSD Provider Agreement application and required policies to PERU. PERU reviews the application for HCBS settings compliance and verifies all local business licenses and staff credentials.

Once approved and enrolled in the YES.NM portal, the agency is added to the state's provider directory. The agency receives referrals when newly allocated waiver participants select them using the Primary Freedom of Choice (PFOC) form.

• Step 1: Obtain local business licenses for all intended service counties.
• Step 2: Submit Provider Agreement application and HCBS settings policies to PERU.
• Step 3: Complete Medicaid enrollment through the YES.NM portal.
• Step 4: Receive participant allocations via the signed Primary Freedom of Choice (PFOC) form.

10. Common Denials and Survey Findings

The Quality Management Bureau (QMB) conducts unannounced surveys of case management agencies to evaluate compliance with CMS waiver assurances and DDSD standards. Deficiencies are issued in a formal Report of Findings.

Agencies that fail to meet Conditions of Participation (COPs) regarding ISP development, level of care, or health and safety must submit a corrective action plan. Failure to implement corrections or maintain local business licenses results in Medicaid termination.

• Plan of Correction (POC) Deadline: Must be submitted within 10 working days of receiving the QMB Report of Findings.
• POC Implementation: The agency has 45 days from the receipt of the report to fully implement the approved POC.
• Survey Focus Areas: ISP development and monitoring, level of care documentation, and participant health, safety, and welfare.
• Administrative Termination: Medicaid numbers are terminated if the agency fails to submit annual business licenses to YES.NM.

11. Key Contacts and Resources

Prospective and current case management providers must interact with multiple HCA divisions for enrollment, credential updates, and survey compliance. The YES.NM portal is the primary hub for Medicaid enrollment and business license uploads.

For DDSD-specific provider agreement updates, staff credential submissions, and Board of Directors reporting, providers communicate directly with the Provider Enrollment Relations Unit (PERU).

• Medicaid Enrollment Portal: YES.NM (https://yes.nm.gov).
• HCA Provider Enrollment Support: 800-299-7304 or [email protected].
• PERU Credential Submissions: [email protected] or fax (505) 476-8894.
• DDSD Case Management Information: https://www.hca.nm.gov/ddw-case-management-services.

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