Text Size

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.

July 27, 2018: New Quick Start Guide for Submitting Home and Community-Based Waiver LOC Documents
The newest quick start guide provides instructions for adding Home and Community-Based waiver level of care documents in the Qualis Health Provider Portal. You can find a link to it on the Provider Resources page under “Qualis Health Provider Portal Resources.”

As of July 1, 2018, Qualis Health staff is building all Home and Community-Based waiver LOC annual reviews in the Qualis Health Provider Portal. Reminder notices will be sent to waiver clients 90 and 45 days prior to their LOC expiration date. Case managers will receive alerts in the Qualis Health Provider Portal.

February 26, 2018: New Provider Checklist for Alternative Benefit Plan Exemption Requests
This new checklist provides guidance on how to request an Alternative Benefit Plan (ABP) exemption. You can also find a link to it on the Provider Resources page under “Provider Checklists.”

January 17, 2018: DD Waiver TPA Coversheet Updated
The Developmental Disabilities Waiver Third Party Assessor Coversheet has been updated. You can find it on the Provider Resources page.

October 9, 2017: Fax Number Updates
The fax numbers for MCO client information update requests and urgent fee-for-service prior authorizations have both been changed to (888) 562-2755. All available fax numbers are listed on the Contacts and Provider Resources pages.

October 9, 2017: ICF/IID Admission Criteria Document Posted
The ICF/IID Admission Criteria document is now on the Provider Resources page.

September 14, 2017: Reminder from New Mexico Medicaid Provider Relations Support
Effective September 5, 2017, the following providers are now required to use the Qualis Health Provider Portal:

  • Fee-for-service providers rendering services requiring prior authorization
  • Developmental Disabilities Waiver case managers
  • Mi Via consultants
  • Medically Fragile case management service providers


We are no longer accepting faxed submissions from these providers.

Find more information in the bulletin from New Mexico Medicaid Provider Relations Support.

September 1, 2017: Three Provider Checklists Added to Resources
Three new checklists are available to help you submit complete, accurate requests:


You can also find these documents on the Provider Resources page under the “Provider Checklists” heading.

August 29, 2017: QHPP Required for ICF/IID and PACE Review Requests
Effective August 28, 2017, Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) and Program of All-Inclusive Care for the Elderly (PACE) review requests must be submitted through the Qualis Health Provider Portal.

Advance registration is required to use the Qualis Health Provider Portal. If you haven’t already registered, please submit a QHPP registration packet. You can also find a link to the packet on the Provider Resources page.

If you have questions, please call Qualis Health at (866) 962-2180, Monday–Friday, 8:00 am–5:00 pm Mountain Time.

August 4, 2017: Coming Soon—QHPP Required for Developmental Disabilities and Medically Fragile Waiver Requests
Effective August 14, 2017, developmental disabilities and medically fragile waiver requests must be submitted through the Qualis Health Provider Portal.

Advance registration is required to use the Qualis Health Provider Portal. If you haven’t already registered, please submit a QHPP registration packet. You can also find a link to the packet on the Provider Resources page.

If you have questions, please call Qualis Health at (866) 962-2180, Monday–Friday, 8:00 am–5:00 pm Mountain Time.

August 1, 2017: QHPP Required for Behavioral Health and Dental Prior Authorization Requests
Effective August 1, 2017, behavioral health and dental prior authorization requests must be submitted through the Qualis Health Provider Portal.

Advance registration is required to use the Qualis Health Provider Portal. If you haven’t already registered, please submit a QHPP registration packet. You can also find a link to the packet on the Provider Resources page.

If you have questions, please call Qualis Health at (866) 962-2180, Monday–Friday, 8:00 am–5:00 pm Mountain Time.

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.

 

 

Adobe Acrobat® PDF files can be opened using Adobe Acrobat Reader. If you do not have Reader, you can get it free from the Adobe website.