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State of New Mexico - Human Services Department


Qualis Health provides third party assessor and utilization review services to the State of New Mexico Human Services Department Medical Assistance Division (HSD/MAD). Our regional office is located in Albuquerque, NM. Qualis Health strives to improve and advance the efficiency, economy, effectiveness and quality of healthcare services provided to enrolled New Mexico Medicaid recipients.


Services We Provide to New Mexico Medicaid

  • Level of Care (LOC) review
    • Mi Via Waiver
    • Medically Fragile Waiver
    • Developmentally Disabled Waiver
    • Program of All Inclusive Care for the Elderly (PACE)
    • Intermediate Care Facilities (ICF/IID)
  • Utilization Management Review for Fee for Service (FFS)
    • Prior Authorization
    • Behavioral Health
    • EMSA


Announcements

Please check this page frequently for updates about provider training and resources.

January 27, 2017: New Mi Via Provider Checklists Published
Two new provider checklists are now online: Mi Via Developmental Disabilities Level of Care Review and Mi Via Medically Fragile Level of Care Review. These replace the Mi Via Level of Care Review checklist. The Provider Resources page also contains links to these checklists.

November 4, 2016: New Provider Notice Describes Feedback Process
In the new Compliments & Complaints Letter, we describe our system for handling feedback from a variety of sources, including clients, providers and patients. This letter is located on the Provider Resources page under the heading “Provider Notices.” We welcome your input!

October 18, 2016: Physical Therapy Review Provider Checklist Added
We have created a provider checklist for physical therapy therapy review submission. You can also find it on the Provider Resources page under the "Provider Checklists" heading.

September 15, 2016: New and Updated Qualis Health Provider Portal Guides Available
We have made some changes to the Qualis Health Provider Portal User Guide, as well as added an Administrator Guide. You can find links to these guides on the Provider Resources page.

July 19, 2016: Two New Training Videos Available for Mi Via Providers
Our Qualis Health Provider Portal training videos now include “Submitting Mi Via Budget Requests” and “Submitting Mi Via LOC Requests.” You can also find links to these videos on our Provider Resources page under the heading “Qualis Health Provider Portal Resources.”

July 13, 2016: UNM C.O.R.E. Budget Quick Start Guide Updated
We have updated the Qualis Health Provider Portal Quick Start Guide for UNM C.O.R.E. Budget Requests. You can find it on the Provider Resources page under the heading “Qualis Health Provider Portal Resources.”

May 24, 2016: Qualis Health Provider Portal Training Video for Dental Providers Completed
Our newest Qualis Health Provider Portal training video is “Submitting Dental Authorization Requests.” You can also find it on our New Mexico Medicaid Provider Resources webpage under the heading “Qualis Health Provider Portal Resources.”

May 18, 2016: Qualis Health Provider Portal Video Training Now Here
We now offer Qualis Health Provider Portal video tutorials. The first two videos are "Submitting Traditional Annual LOC Requests" and "Submitting Traditional Budget Requests," and you can find them on the Provider Resources page under the heading "Qualis Health Provider Portal Resources."

April 26, 2016: Two New Provider Checklists Available
We have posted two new checklists: Acute Rehabilitation Hospital Review and Non-DRG LTAC Hospital Review. You can also find them on the Provider Resources page under the heading “Provider Checklists.”

April 11, 2016: Attention New Mexico Fee-For-Service Dental Providers
A systems-related electronic transfer error between Qualis Health and Xerox has been identified which is impacting dental prior authorizations for the same procedure code with different oral cavity codes. This may result in codes that were approved by Qualis Health but are otherwise missing from the prior authorization in the Xerox system. Therefore, Qualis Health is manually updating individual prior authorizations while the issue is being resolved by Xerox. Should you experience a non-payment for this reason, please fax the following information to our dental fax queue at 1-877-717-8592 so that we may update the prior authorization.

  • Indicate the issue as dental prior authorization for same procedure code with different oral cavity codes
  • Patient’s name
  • DOB
  • Authorization #
  • Exact Date of Service
  • Service Code being billed


March 4, 2016: Jackson Class Urgent Fax Number Now Available
We have added a fax number for urgent faxes related to Jackson class members. This toll-free number is (877) 850-7269. You can also find it on the Contacts page and the Provider Resources page.

February 19, 2016: New Provider Checklist Online
The Out-of-State Service Request provider checklist is now available. You can also find it on the Provider Resources page under the “Provider Checklists” heading.

February 18, 2016: Submit Review Requests Online Using the Qualis Health Provider Portal
Use our secure web-based system, the Qualis Health Provider Portal, to submit your review requests. This convenient, efficient tool is available 24/7 and will help you receive quick responses.

  • Registration: Before you can use the Qualis Health Provider Portal, you must complete and submit a registration packet. You can also find the registration packet on the Provider Resources page under the heading “Getting Started: Register.”
  • Training: We are holding multiple Qualis Health Provider Portal training webinars in March and April. Visit the Provider Education page to get all of the details, including dates, times and how to register.
  • Reference: For your reference, Qualis Health Provider Portal Quick Start Guides are posted on the Provider Resources page under the heading “Qualis Health Provider Portal Resources.”


Download Flyers to Learn More About the Services We Provide to New Mexico Medicaid

  • Download this flyer for more information about the Level of Care Review services we provide and how to access those services.
  • Download this flyer for more information about the Utilization Management Review for Fee for Service services we provide and how to access those services.