NMSTAR Vendor Manual

Introduction

Falling Colors (FC) is a New Mexico-based company with a history of success in working with behavioral healthcare Vendors processing financial and client data for grants and state-funded services. We operate with integrity and efficiency, providing the best service and value to the State of New Mexico and its healthcare Vendors. Falling Colors is dedicated to improving the health and well-being of all New Mexicans. We believe that supporting Vendors by handling their required billing and data collection in an efficient, friendly, and supportive manner will benefit our entire behavioral health system. We are enthusiastic about the future of behavioral health in New Mexico, and we are proud to be a part of that future with you.

Online Resources

User Manuals, Guides, Videos, and Trainings

Feel free to review our Confluence space for all training methods and opportunities. Falling Colors provides training to vendors on a variety of topics.

Training resources include general NMSTAR user guides, how-to guides, and video demonstrations. In addition, webinars and virtual training will be scheduled as needed.

Support Desk

All issues encountered and questions about NMSTAR should be directed to support@fallingcolors.com

Emails sent to support are then generated into a Support Ticket and handled in our support desk application.

Please refer to the Support Desk FAQ posted here: https://fallingcolors.freshdesk.com/support/solutions for additional information on resolution timelines and managing and viewing your support tickets.

Please do not send protected client information to support. Please only refer to them by their NMSTAR Client ID.

Support operates 8 am-5 pm MT, Monday-Friday, except holidays.

Glossary

Behavioral Health Billed Projects: A ‘Project’ is defined as specific funding for a clearly defined intention with a target population and approved service mix under which one or more providers may be participating. Projects can be supported by multiple funding streams as defined by the Collaborative.

Behavioral Health Services Division (BHSD): New Mexico Human Services Department division providing a variety of behavioral health services to adults in New Mexico.

NMSTAR System: An information management system integral to the operation of non-Medicaid behavioral health services which supports multiple functions, including but not limited to registration of Vendors and Clients, billing, and data reporting. All references to the NMSTAR System shall be understood to include any future version or iteration of the NMSTAR System, as well as any complementary or ancillary system, developed by Falling Colors for the Collaborative.

Business Days: Monday through Friday, except for State or Federal Holidays.

Children Youth and Families Department (CYFD): State of New Mexico department providing a variety of services, including behavioral health services, to New Mexico children and their families.

Client: For purposes of this manual, a person with a mental health or substance abuse disorder who is receiving, has received, or is eligible to receive Behavioral Health services through this Agreement.

Client Eligibility: Verification that a client is not eligible for Medicaid service reimbursement for a specific date of service and service code which is done here: https://nmmedicaid.acs-inc.com. Additionally, certain projects funded by BHSD or CYFD have client eligibility criteria associated with them that are specific to each project’s purpose.

Client Registration: Online process to register non-Medicaid clients for whom services are provided and billed through NMSTAR.

Collaborative or The Interagency Behavioral Health Purchasing Collaborative: The Collaborative, established pursuant to NMSA 1978, §9-7-6.4, is responsible for planning, designing, and directing the statewide Behavioral Health System.

Credentials: Eligibility or licensure of an individual to perform services provided they have met specified qualifications and defined requirements.

Collaborative Members or Member Agencies: The agencies that are members of the Collaborative and which can elect to fund non-Medicaid Behavioral Health services through the ASO under this Agreement. The members individually are referred to as a Member Agency.

Deemed Credentialed: Vendors who are credentialed with a New Mexico Medicaid Managed Care Organization at the time this Agreement is signed will be considered to represent current credentialing or re-credentialing with Falling Colors.

Early Childhood Education and Care Department (ECECD): State of New Mexico department that provides early childhood programs and services.

HIPAA: Health Insurance Portability and Accountability Act

Managed Care Organization (MCO): A health care delivery system consisting of affiliated and/or owned hospitals, physicians, and others that provide a wide range of coordinated health services; an umbrella term for health plans that provide health care in return for a predetermined monthly fee and coordinate care through a defined network of physicians and hospitals. Examples: Health Maintenance Organization(HMO) Point Of Service Plan (POS), and Preferred Provider Organization(PPO).

State Scope of Work (SOW): A description of the agreed-upon terms of work to be completed in the execution of the Agreement. The SOW may or may not include a fee schedule in addition to or in place of a description of work.

Vendor-A provider rendering non-Medicaid services within the State of New Mexico.

Vendor Administrator: Person responsible for gathering information listed on the vendor registration checklist, entering the information online, and submitting the completed registration in NMSTAR.

Vendor Authority: New Mexico state agencies (BHSD, CYFD, and ECECD) are responsible for approving vendors for contracts for behavioral health services.

Vendor Information Worksheet: Excel document used by vendors to provide the information needed to configure Vendor’s registration structure.

Vendor Manual: A resource for behavioral health Vendors, updated periodically, to communicate any pertinent information to providers of non-Medicaid behavioral health services.

Vendor Registration: Online process for Vendors to request contracts to provide non-Medicaid behavioral health services funded by Vendor Authorities (BHSD and/or CYFD).

Vendor Registration Checklist: List of information needed to complete Vendor Registration that includes business information, business addresses, and contacts, MCO credentialing, vendor services information, required vendor documents, and vendor staff information.

Vendor Expectations

Notification to Falling Colors of Facility and/or Clinician Changes

We require that Vendors notify us in writing within 10 calendar days of any changes related to:

Vendor Details: changes in ownership, locations/addresses, or contact details
Professional Liability Insurance changes
Tax ID Number (TIN) used for claims filing
Professional Licensure/Certification: changes such as revocation, suspension, restriction, probation, termination, reprimand, inactive status, voluntary relinquishment, or any other adverse action
Services offered
Staff licensure/credentials
W-9 or EFT changes

Many of these changes can be handled online via our Vendor Registration. Changes submitted in writing should be directed to support@fallingcolors.com. Failure to report changes within the guidelines may result in payment delays and could affect your lead agency network participation standings.

Professional Responsibilities

In accordance with the Vendor Contract, you are required to provide client services in a manner that is consistent with professional and legal standards applicable at the time of service regardless of a consumer’s benefit plan or terms of coverage. Providers should post and/or make available to their clients Consumer Rights information.

National Provider Identifier (NPI)

A National Provider Identifier (NPI) is a 10-digit unique identification number issued to health care Vendors by the Centers for Medicare and Medicaid Services (CMS). All individual HIPAA-covered healthcare Vendors such as: physicians, pharmacists, physician assistants, midwives, nurse practitioners, nurse anesthetists, dentists, denturists, chiropractors, clinical social workers, professional counselors, physical therapists, occupational therapists, pharmacy technicians, athletic trainers, etc.) or organizations (hospitals, home health care agencies, nursing homes, residential treatment centers, group practices, laboratories, pharmacies, medical equipment companies, etc.) must obtain an NPI for use in all HIPAA standard transactions, even if a separate billing agency prepares the actual transactions.

Please visit the CMS website for additional information and details on how to request an NPI: https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/apply.html

The Americans with Disabilities Act

Vendors are expected to comply with The Americans with Disabilities Act. This includes, but is not limited to, protections against discrimination that limit or prevent access to services based on the presence of the disability, and modifications to facilities or equipment that accommodate individuals to gain access to services offered for which they are eligible.

HIPAA

Health Insurance Portability and Accountability Act (effective August 21, 1996)

Protects the transmission of personal health information (PHI)
Standardizes codes for health care transactions
Sets conditions for the use and disclosure of PHI
Establishes security standards to ensure data integrity

Falling Colors is compliant with required HIPAA privacy and security rules as well as other applicable New Mexico state and federal laws regarding privacy, confidentiality, release, and maintenance of consumer information, including substance or alcohol abuse. Annual refresher training is conducted annually.

Vendors are required to:

Train staff regarding HIPAA and the use and disclosure of Protected Health Information (PHI).
Maintain records dealing with HIPAA privacy issues for at least 6 years.
Comply with HIPAA privacy and security rules.

Alcohol or Substance Abuse Disclosures (CFR-42)

The Federal Substance Abuse Regulations apply to information that could directly or indirectly identify a consumer as an alcohol or substance abuser. Although HIPAA covers substance abuse information, the federal substance abuse regulations are more restrictive than HIPAA and do not allow disclosure without the consumer's written consent except in very limited circumstances (i.e., the federal substance regulations do not contain a “treatment” exception as HIPAA does).

Vendors are required to:

Train staff regarding the use and disclosure of Alcohol and Substance Abuse information.
Comply with Federal Substance Abuse Regulations.

Information Security Awareness

By participating in State or Federally funded programs, managed by Falling Colors, the Vendor attests to implementing an information security awareness program in its organization that covers: data, networks, user conduct, social media, mobile devices, and social engineering.

Service Prior-Authorization

The Collaborative has removed the requirements of prior authorization for services supported with non-Medicaid behavioral health funds. Billing for services previously requiring prior authorization will be monitored and evaluated for appropriateness.

Continuation of Services after Termination

If the Vendor terminates their Agreement for any reason, or in the event, any individual Client ceases to receive care or treatment from Vendor, Vendor shall cooperate and take all reasonable steps to ensure a smooth transfer of the Client to a new Vendor in collaboration with the Collaborative and/or Falling Colors.

Billing for No Shows

Vendors cannot bill for no-shows.
Vendors should not charge a deposit or advance payment for a potential missed appointment or no-show.
Vendors may not bill for services not rendered.

Timely Filing

Falling Colors must ensure compliance with the following timeframes for Vendors to submit all Claims, Workbooks, and/or Encounters to Falling Colors:

Vendors have

Until Midnight on the last day of the month following the month of service to submit claims, workbooks, invoices, and/or encounters; and
Thirty (30) days from the date a correction is required to submit the corrections.

Vendor Registration

All Vendors wishing to provide non-Medicaid services for The New Mexico Behavioral Health Services Division, and The New Mexico Children, Youth, and Families Department must complete and submit the online vendor registration documents. Please note, initiating Vendor Registration does not guarantee funding through the Behavioral Health Collaborative agencies (ALTSD, BHC, BHSD, CYFD, DDC, DOH, ECECD, and HED).

Vendor Registration Process - Overview

Lead Agency reaches out to Falling Colors Support (support@fallingcolors.com) to register a new provider. The Lead Agency must submit this approved request along with the Vendor’s approved Scope of Work (SOW) and the Vendor’s contact information.
*FCC needs Lead Agency approval written and the SOW included in order to register any new Vendors in STAR or contract with FCC.
FC Support creates STAR Vendor Profile and Vendor Administrator account. FC Support reaches out to Vendor’s designated STAR Vendor Administrator with the required Vendor Registration Documents (EFT form and W-9) and and asks them to complete and submit the profile and to let us know.
*The designated Vendor Administrator is the person who will be completing the online Vendor registration. Vendor billing and claims submission is a different process with distinct Administrative permission. Vendors will need to register their appropriate billing staff separately.
FC Support sends required FCC Contracts and Lead Agency Approved SOW to Vendor’s designated Signatory Authority via SignEasy for review and signature.
*Falling Colors will make 4 attempts to contact and remind providers about unsigned documents. After 1 month we will then inform the member agency of the unsigned documents and cease attempts to contact.
Vendor Administrator completes all sections of registration including business profile, staff profiles, and business services then Submits Online Registration. The Vendor Administrator notifies FC Support (support@fallingcolors.com) that completed registration has been submitted.
FC Support will conduct preliminary checks on Vendor’s submitted registration.
1. If it passes preliminary checks, Vendor Registration will be approved and EFT will be added to Profile- registration complete in NMSTAR.
2. If it does NOT pass preliminary checks, FC Support will contact the Vendor by email to request the needed information to complete their registration.
Once profile is approved/EFT configured, FC Support will send required Annual Attestation to Vendor for completion via STAR.
*Falling Colors will make 4 attempts to contact and remind providers about unsigned documents. After 1 month we will then inform the member agency of the unsigned documents and cease attempts to contact.
Vendor’s Signatory Authority signs required FCC Contracts and Lead Agency Scope of Work, then FC Support notifies Lead Agency that the Vendor is registered in NMSTAR and has signed the required contracts and are ready to receive their allocation in NMSTAR.
*Falling Colors will make 4 attempts to contact and remind providers about unsigned documents. After 1 month we will then inform the member agency of the unsigned documents and cease attempts to contact.

**Note: For Claims, additional testing is required-Please refer to the Claims Processing section.***

Credentialing

By its execution of the Vendor’s agreement, the Vendor certifies and affirms that it has all necessary professional licensure, accreditation, certifications, credentialing, and continuing education required to perform all services the Vendor is contracted to perform under the State SOW, and that it complies with any and all continuing requirements. The Vendor agrees to make evidence of compliance with all such requirements under this Agreement available to Falling Colors and/or the Member Agency requesting such evidence upon three (3) Business Days advance written notice to Vendor.

The Vendor shall comply with all applicable local, state, and federal laws and regulations including but not limited to all professional and health facility licensing and certification requirements and any other applicable legal requirements.
The Vendor shall comply with all applicable local, state, and federal laws and regulations relating to the care and treatment of all Clients including minors, as defined by the State of New Mexico.
On confirmation by Falling Colors that Vendor has submitted documentation reflecting all necessary accreditation or professional licensure requirements and has been Deemed Credentialed with a New Mexico Medicaid Managed Care Organization (MCO) to provide all services anticipated under the State SOW, Falling Colors will accept the Vendor as appropriately credentialed and provide Vendor access to the STAR System. Falling Colors, the Collaborative Member Agency, and the Collaborative Member Agency’s designated entity shall have the right to audit such accreditation and licensure criteria upon three (3) Business Days advance written notice to Vendor.

Vendor understands that Falling Colors and the Collaborative rely on Vendor’s representations regarding licensure and credentialing, as well as compliance with applicable laws, and agrees to defend and indemnify Falling Colors, the Collaborative, and the State of New Mexico for any breach of this section or as described more fully in Article 16 of the Vendor’s Agreement.

Client Eligibility and Registration

Vendors are responsible to determine the eligibility of a client at the time service is rendered. Non-Medicaid funds are intended for services to individuals not covered by Medicaid. Vendors must check the Medicaid portal prior to administering a service for non-Medicaid reimbursement. By submitting a service for non-Medicaid reimbursement, Vendors are attesting that they have verified a client’s non-Medicaid eligibility. Done here: https://nmmedicaid.acs-inc.com

Depending on the specifics of the scopes of work, additional eligibility criteria may exist. If you are unsure of the eligibility of a client for the non-Medicaid funding you are receiving, please contact your State Agency program manager.

For Vendors submitting claims or encounters, you must also register your client in STAR prior to delivery of services. Specifics and How-To Guides on the client registration process are located at bhsdstar.org.

Claims Processing

Falling Colors will process claims for BHSD and/or CBHD non-Medicaid services.

Claims can be submitted to Falling Colors through our Clearinghouse Claim MD. http://www.claim.md

Providers can enroll with Claim MD at https://www.claim.md/fallingcolors/ and submit claims via manual entry or via electronic upload of an 837P or 837I. There is no cost to the provider for submitting claims directly to Falling Colors via Claim MD. (existing Claim MD customers do not need to re-enroll, but will just submit a claim using payer ID FCC20).

Providers can also submit claims to Claim MD via an already established relationship with their own Clearinghouse. Please ask your Clearinghouse to contact Claim MD at (855) 757-6060. Our Payer ID is FCC20.

Providers that will be submitting claims will need STAR system access for the Claims Project to pre-register the claims clients. Please fill out the staff registration form located on the Manuals & Forms tab and submit it to support@fallingcolors.com

If you have any questions, please contact us at support@fallingcolors.com

For details on 837 P and I required fields refer to the 837 Companion Guide at bhsdstar.org on the Manuals & Forms tab.

Payments

All submitted claims and/or encounters will be bundled into a NMSTAR Invoice on the 1st and 16th of each month for payment.

Member Agency program managers will review and approve encounter-based invoices for payment.
Claims invoices are pre-approved by Member Agencies for payment.

All submitted workbooks will be processed into a NMSTAR invoice at midnight of the day they are submitted.

Member Agency program managers will review and approve workbook-based invoices for payment.

All payments will be made no later than 30 days from the date of invoice approval.

Vendor Auditing and Recoupment

Medicaid Recoupment

Falling Colors, Inc., as the Administrative Services Organization (ASO) for The Behavioral Health Collaborative, is the payer of last resort for BH services funded by the Behavioral Health Services Division (BHSD). Services for members covered under Medicaid benefits must be billed to the Managed Care Organization (MCOs) or Fee for Service (FFS) Medicaid. Likewise, services covered by other third-party payers, whether public or private, must be billed to the appropriate payer(s). Services covered by Medicaid or other payers that have been billed inappropriately to Falling Colors but paid will be recouped by BHSD and CYFD. Also, non-Medicaid funds cannot be used to balance bill the unpaid portion of billing by another payer, such as deductibles, co-pays, or amounts exceeding treatment limits.

Audits of payments for Non-Medicaid services will occur on an ongoing basis. BHSD and CYFD have set rules in place to audit claims paid through non-Medicaid funds. The rules can be viewed on bhsdstar.org Manuals & Guides tab Medicaid Recoupment document under the QA Review section. The recoupment details are intended to assist providers on how to appropriately bill non-Medicaid funding.

If a Vendor is petitioning a decision for recoupment of payments made by the Lead Agency, the Vendor is confirming they can provide sufficient supporting documentation for all petitioned records. This documentation should be included in the initial petition made to the Lead Agency.

Service Audits

BHSD and CYFD have the right to audit Non-Medicaid service billings both before and after payment. They have the ability to define a Selection Set from the pool of outstanding and paid services to conduct audits at any time. Vendors will be required to make repayment of any funds expended by the Collaborative, subject to which an auditor with the jurisdiction and authority finds were expended, or to which appropriate federal funding agencies take exception, and so request reimbursement through a disallowance or deferral based upon the acts or omissions of the ASO that violate applicable federal statutes and/or regulations.

Disputes and Grievances

Should the Vendor have questions regarding payment the Vendor should address their questions, comments, or concerns to support@fallingcolors.com. Falling Colors will provide reasonable help to the Vendor in these types of requests or will forward those requests to the Collaborative. If Vendor is dissatisfied with any decision related to payment, Vendor agrees to address its grievance or dissatisfaction solely with the Collaborative Member Agency.