• New Mexico Medicaid Portal


INFORMATION
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  • This agreement is for groups, organizations, or individual applicants to whom payments will be made. If the applicant is an individual applying for a provider number only for identifying services billed through a group practice or other organization and payments will be made to that group or organization, then this form should not be used. Use Form MAD 312 instead.
    Fee-For-Service (FFS) and Managed Care Organization (MCO) network or Fee-For-Service (FFS) only. 
    • New Mexico Medicaid general Provider Policy (NMAC 8.302.1) requires that a provider must be enrolled in Electronic Fund Transfer (EFT) in order to receive Fee-for Service (FFS) reimbursement. You have the ability to include EFT information with your provider enrollment application. EFT is required to be an active Medicaid provider. 
    Managed Care Organization (MCO) network only. 
  • This agreement is for individual applicants who perform services within a group or other organization. Payments will be made only to the group or organization.  No payments will be made directly to the individual.  If the applicant will be providing services for which payments are to be made directly to the applicant, then this form should not be used.  Use Form MAD 335 Instead.
    Fee-For-Service (FFS) and Managed Care Organization (MCO) network or Fee-For-Service (FFS) only. 
    Managed Care Organization (MCO) network only. 
  • Select if you are an MCO registering a restricted provider.
    MAD 012 (groups, organizations, facilities, or individual providers to whom payments are made)
    MAD 013 (individual providers rendering services as part of a group or organization)
  • Select if this application is for a Presumptive Eligibility Determiner or Provider.
  
   
This Application Is :

Select to complete a new application for the NM Medicaid program.