The definitions in 11.4.1.7 NMAC shall apply to this rule. In addition, the following definitions apply to the provision of all services.

1. A. “Business day” means any day on which the WCA is open for business.
2. B. “By-Report (BR)” means a maximum amount for a service has not been established in the HCP fee schedule.
3. C. “Cannabis Program” means the State of New Mexico Department of Health Medical Cannabis Program.
4. D. “Caregiver” means any provider of health care services not defined and specified in Section 52-4-1 NMSA 1978.

5. E. “Case management” means the on-going coordination of health care services provided to an injured or disabled worker including, but not limited to:

   1. (1) developing a treatment plan to provide appropriate health care service to an injured or disabled worker;
   2. (2) systematically monitoring the treatment rendered and the medical progress of the injured or disabled worker;
   3. (3) assessing whether alternate health care services are appropriate and delivered in a cost-effective manner based upon acceptable medical standards;
   4. (4) ensuring that the injured or disabled worker is following the prescribed health care plan; and,
   5. (5) formulating a plan for the return to work.
6. F. “Contractor” means any organization that has a legal services agreement currently in effect with the workers' compensation administration (WCA) for the provision of utilization review or case management or peer review services.
7. G. “Corrected claim” means a claim that has already been processed by the payer, whether paid or denied, and is resubmitted with additional charges, different procedure or diagnosis codes or any information that would change the way the claim originally processed.
8. H. “Current procedural terminology (“CPT®”)” means a systematic listing and coding of procedures and services performed by HCPs of the American medical association, adopted in the director’s HCP fee schedule order. Each procedure or service is identified with a numeric or alphanumeric code (CPT® code). This was developed and copyrighted by the American medical association. The five character codes included in the rules governing the health care provider fee schedule are obtained from current procedural terminology (CPT®), by the American medical association (AMA). CPT® is developed by the American Medical Association (AMA) as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians. The responsibility for the content of the rules governing the health care provider fee schedule is with WCA and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in rules governing the health care provider fee schedule. Fee schedules, relative value units, conversion factors or related components are not assigned by the AMA, are not part of CPT®, and AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Any use of CPT® outside of rules governing the health care provider fee schedule should refer to the most recent edition of the current procedural terminology which contains the complete and most current listing of CPT® codes and descriptive terms. Applicable FARS/DRARS apply. CPT® is a registered trademark of the American medical association.
9. I. “Diagnostic and statistical manual of mental disorders (DSM)” means the current edition of the manual, which lists and describes the scientifically diagnosed mental disorders and is commonly referred to as “DSM”.
10. J. “Department of health (DOH)” means the state of New Mexico department of health.
11. K. “Director” means director of the workers' compensation administration (WCA) or designee.
12. L. “Durable medical equipment (DME)” means supplies and equipment that are rented, leased, or permanently supplied to a patient and which have been prescribed to aid the recovery or improve the function of an injured or disabled worker.
13. M. “Employer” means, collectively: an employer subject to the act; a self-insured entity, group or pool; a workers' compensation insurance carrier or its representative; or any authorized agent of an employer or insurance carrier, including any individual owner, chief executive officer or proprietor of any entity employing workers.
14. N. “Freestanding ambulatory surgical center (FASC)” means a separate facility that is licensed by the New Mexico department of health as an ambulatory surgical center.
15. O. “Healthcare Common Procedure Coding System (HCPCS)” means a set of health care procedure codes based on the American Medical Association’s Current Procedural Terminology (CPT®).
16. P. “Health care provider (HCP) or provider” means any person, entity, or facility authorized to furnish health care to an injured or disabled worker pursuant to Section 52-4-1 NMSA 1978, including any provider designated pursuant to Section 52-1-49 NMSA 1978, and may include a provider licensed in another state if approved by the director, as required by the act. The director has determined that certified registered nurse anesthetists (CRNAs) and certified nurse specialists (CNSs) who are licensed in the state of New Mexico are automatically approved as health care providers pursuant to Subsection P of Section 52-4-1 NMSA 1978.
17. Q. “HCP fee schedule” means the WCA Health Care Provider Fee Schedule & Billing Instructions document and is used for ease of reference.
18. R. “Hospital” means any place currently licensed as a hospital by the department of health pursuant to Section 52-4-1(A) NMSA 1978, where services are rendered within a permanent structure erected upon the same contiguous geographic location as are all other facilities billed under the same name.

19. S. “Implants, instrumentation and hardware” means:

    1. (1) surgical implants are defined as any single-use item that is surgically inserted, deemed to be medically necessary and approved by the payer which the physician does not specify to be removed in less than six weeks, such as bone, cartilage, tendon or other anatomical material obtained from a source other than the patient; plates, screws, pins, cages; internal fixators; joint replacements; anchors; permanent neurostimulators; and pain pumps;
    2. (2) disposable instrumentation includes ports, single-use temporary pain pumps, external fixators and temporary neurostimulators and other single-use items intended to be removed from the body in less than six weeks.
20. T. “Independent medical examination (IME)” means a specifically requested evaluation of an injured or disabled worker's medical condition performed by an HCP, other than the treating provider, as provided by Section 52-1-51 NMSA 1978.
21. U. “Licensed producer” means an individual or entity located in New Mexico licensed and certified by the department of health to produce, manufacture, or dispense medical cannabis.
22. V. “Medical cannabis” means medical cannabis in the form of flower, bud, cannabis derived products, edibles, oils, tinctures, or any other form regulated by the department of health.

23. W. “Medical records” means:

    1. (1) all records, reports, letters, and bills produced or prepared by an HCP or caregiver relating to the care and treatment rendered to the worker;
    2. (2) all other documents generally kept by the HCP or caregiver in the normal course of business relating to the worker, including, but not limited to, clinical, nurses' and intake notes, notes evidencing the patient's history of injury, subjective and objective complaints, diagnosis, prognosis or restrictions, reports of diagnostic testing, hospital records, logs and bills, physical therapy records, and bills for services rendered, but does not include any documents that would otherwise be inadmissible pursuant to Subsection C of Section 52-1-51 NMSA 1978.
24. X. “New Mexico gross receipts tax (NMGRT)” means the gross receipts tax or compensating tax as defined in Chapter 7, Article 9 of the New Mexico Statutes Annotated 1978 (the “Gross Receipts and Compensating Tax Act”). This tax is collected by the New Mexico taxation and revenue department.
25. Y. “Peer review” means an individual case by case review of services for medical necessity and appropriateness conducted by an HCP licensed in the same profession as the HCP whose services are being reviewed.

26. Z. “Physical impairment ratings (PIR)” means an evaluation performed by an MD, DO, or DC to determine the degree of anatomical or functional abnormality existing after an injured or disabled worker has reached maximum medical improvement. The impairment is assumed to be permanent and is expressed as a percent figure of either the body part or whole body, as appropriate, in accordance with the provisions of the Workers' Compensation Act and the most current edition of the American medical association's guides to the evaluation of permanent impairment (AMA guide).

    AA. “Prescription drug” means any drug, generic or brand name, which requires a written order from an authorized HCP for dispensing by a licensed pharmacist or authorized HCP.

    BB. “Provider’s Report of Physical Ability (PROPA)” means the WCA form available to all parties on the WCA agency website which may be completed by HCPs.

    CC. “Referral” means the sending of a patient by the authorized HCP to another practitioner for evaluation or treatment of the patient and it is a continuation of the care provided by the authorized HCP.

    DD. “Services” means health care services, the scheduling of the date and time of the provision of those services, procedures, drugs, products or items provided to a worker by an HCP, pharmacy, supplier, caregiver, or freestanding ambulatory surgical center which are reasonable and necessary for the evaluation and treatment of a worker with an injury or occupational disease covered under the New Mexico Workers' Compensation Act or the New Mexico Occupational Disease Disablement Law.

    EE. “Telemedicine services” means a two-way, real time interactive communication between the worker and the provider at a distant site. At a minimum, telemedicine includes audio and video telecommunications equipment.

    FF. “Telephonic services” means non-face to face services provided to a patient using the telephone. Such services can include medical discussions, between a physician or other healthcare professional and a patient, that do not require direct, in person contact.

    GG. “Unlisted service or procedure” means a service performed by an HCP or caregiver which is not listed in the edition of the American medical association’s current procedural terminology referenced in the director’s HCP fee schedule order or has not otherwise been designated by these rules.

    HH. “Usual and customary fee” means the monetary fee that a practitioner normally charges for any given health care service. It shall be presumed that the charge billed by the practitioner is that practitioner's usual and customary charge for that service unless it exceeds the practitioner's charges to self-paying patients or non- governmental third party payers for the same services and procedures.

    II. “Utilization review” means the evaluation of the necessity, appropriateness, efficiency, and quality of health care services provided to an injured or disabled worker and may include peer group utilization review of selected provider services as set forth in Section 52-4-2 NMSA 1978.

    JJ. “Worker” means an injured or disabled employee.

    [CPT® only copyright American Medical Association. All rights reserved.]

[11.4.7.7 NMAC - Rp, 11.4.7.7 NMAC, 1/1/2023]