{"data":{"id":"us-nm/27-11-2","jurisdiction":"us-nm","citation":"27-11-2","heading":"Definitions.","body":"As used in the Medicaid Provider and Managed Care Act:\nA. \"claim\" means a request for payment for services;\nB. \"clean claim\" means a claim for reimbursement that:\n(1) contains substantially all the required data elements necessary for accurate adjudication of the claim without the need for additional information from the medicaid provider or subcontractor;\n(2) is not materially deficient or improper, including lacking substantiating documentation required by medicaid; and\n(3) has no particular or unusual circumstances that require special treatment or that prevent payment from being made in due course on behalf of medicaid;\nC. \"credible\" means having indicia of reliability after the state has reviewed all allegations, facts and evidence carefully and acted judiciously on a case-by-case basis;\nD. \"credible allegation of fraud\" means an allegation that has been verified by the state from any source, including fraud hotline complaints, claims data mining and provider audits;\nE. \"department\" or \"authority\" means the health care authority;\nF. \"fraud\" means any act that constitutes fraud under state or federal law;\nG. \"managed care organization\" means a person eligible to enter into risk-based prepaid capitation agreements with the authority to provide health care and related services;\nH. \"medicaid\" means the medical assistance program established pursuant to Title 19 of the federal Social Security Act and regulations issued pursuant to that act;\nI. \"medicaid provider\" means a person that provides medicaid-related services to recipients;\nJ. \"overpayment\" means an amount paid to a medicaid provider or subcontractor in excess of the medicaid allowable amount, including payment for any claim to which a medicaid provider or subcontractor is not entitled;\nK. \"person\" means an individual or other legal entity;\nL. \"recipient\" means a person whom the authority has determined to be eligible to receive medicaid-related services;\nM. \"secretary\" means the secretary of health care authority; and\nN. \"subcontractor\" means a person that contracts with a medicaid provider or a managed care organization to provide medicaid-related services to recipients.","path":["Chapter 27 - Public Assistance","ARTICLE 11 Medicaid Providers"],"source_url":"https://nmonesource.com/nmos/nmsa-unanno/en/item/18527/index.do","current_through":"2026-07-01","vintage":"","retrieved_at":"2026-09-03T15:02:19Z","sha256":"91aaad91ba422b96212b8eb49dacc76bf068727420a407eb7197a104c00f2bc6","source_id":"us-nm","stale":false,"prev":"us-nm/27-11-1","next":"us-nm/27-11-3"},"notice":"GroundRules: Original legal text. Not legal advice."}