Telehealth follow-up for New Mexico adults after a hospital or facility stay, help with home oxygen and equipment documentation, and ongoing chronic care. Choose who you are:
Referrals go only through secure, HIPAA-compliant channels, or call us. Please don’t include patient details in email.
Hospitals & facilities
Case Managers & Discharge Planners
Refer adults in New Mexico who are going home after a hospital, observation, skilled nursing, rehab, or long-term acute care stay and need a follow-up visit by telehealth.
Who to refer
Adults 18+ who will be in New Mexico for visits
Discharging to home, assisted living, a group home, or a nursing facility
Able to join a video or phone visit (a caregiver can help)
Please send securely
Discharge summary and diagnoses
Reconciled discharge medication list
Pending results, follow-up needs, home health or DME orders
Patient and caregiver contact information
Insurance information
Medicare transitional care requires contact with the patient within 2 business days of discharge and a visit within 7 or 14 days, so please refer at or before discharge.
When a patient needs a treating practitioner for home oxygen or other equipment documentation, we can see them by telehealth and, if clinically appropriate, provide the documentation Medicare requires.
What we can provide
Telehealth face-to-face encounter documentation
Review of a qualifying oxygen test performed by a qualified provider
Standard written order, when medically appropriate
Group II/III: review of the repeat qualifying test (61st–90th day) and a new order
Please send securely
Qualifying test report (ABG or oximetry: date, conditions, and who performed it)
Hospital discharge records, if recent
Current order, equipment, and liter flow
Patient contact and insurance information
We don’t perform oxygen testing. Medicare doesn’t accept tests performed or paid for by a supplier. Orders are written only when clinically supported, and patients choose their own supplier.
Secure online referral is coming soon. Until it’s live, please call 505-977-9174 and we’ll arrange a secure way to receive records. Please do not send personal health information by email.
For DME & home oxygen suppliers
Home Oxygen Orders & Recertification
When your patient needs a treating practitioner for a new oxygen order, a Group II or III 61st–90th day retest, or an updated order, we can see them by telehealth and, if it’s clinically appropriate, complete the documentation Medicare requires. We work with any supplier the patient chooses.
What we provide
A telehealth visit (video, or phone when video isn’t possible) documenting the patient’s condition, symptoms, and need for oxygen. Medicare accepts telehealth for the face-to-face encounter when telehealth rules are met.
Review and documentation of the qualifying test: we evaluate the result and record it in the medical record, including test conditions (at rest, with exercise, or during sleep).
Ordering the qualifying test when one is needed (see “How qualifying testing is arranged” below).
A standard written order, signed before delivery, when medically appropriate: equipment, liter flow, and frequency of use.
Continued-need documentation and new orders when equipment, liter flow, or the patient’s supplier changes.
Please know
We are a telehealth-only practice. We don’t perform oxygen testing. Qualifying tests are done in person at a hospital, lab, testing facility, or clinic, except home overnight oximetry run by a Medicare-enrolled testing facility (IDTF).
Medicare doesn’t accept qualifying tests performed by an oxygen supplier or paid for by one.
An order is written only after our own evaluation, and only when the medical record supports it. A signed form alone isn’t enough.
Patients must be adults located in New Mexico at the time of the visit.
How qualifying testing is arranged
Medicare requires the test to be done at the “time of need” and ordered and evaluated by the treating practitioner. Depending on the situation, we’ll use one of these routes:
Recent hospital test
For a patient leaving the hospital, a qualifying test done within 2 days of discharge counts. Please send the report with the referral.
In-person test near the patient
We order resting or exercise oximetry, or an arterial blood gas, at a hospital, lab, testing facility, or clinic convenient for the patient, then review the result. Exercise qualification needs three readings in one session: at rest without oxygen, during exercise without oxygen, and during exercise with oxygen.
Home overnight oximetry
For oxygen during sleep, we can order stand-alone overnight oximetry directly from a Medicare-enrolled IDTF, which instructs the patient and sends the results to us. Oxygen qualified only during sleep covers stationary equipment, not portable.
Medicare rules at a glance
A plain-language summary for suppliers. The Medicare policy documents linked at the bottom of this page are the official rules.
Face-to-face & order
Visit within 6 months, order before delivery
Home oxygen equipment is on Medicare’s Face-to-Face Encounter and Written Order Prior to Delivery list. A practitioner visit (telehealth allowed) must occur within 6 months before the order, and the signed written order must reach the supplier before delivery.
Standard written order
What’s on the order
Patient name or Medicare number, order date, item description, quantity if applicable, the practitioner’s name or NPI, and the practitioner’s signature. We also include liter flow and frequency of use.
Groups
Group I, II, and III
Group I: saturation 88% or less (or PO2 55 mm Hg or less) at rest, with exercise, or during sleep. Group II: saturation of 89% (or PO2 56–59) plus edema suggesting heart failure, pulmonary hypertension or cor pulmonale, or a hematocrit over 56%. Group III: a normoxemic condition shown to improve with oxygen.
Recertification
Group II & III: 61st–90th day retest
For payment to continue, a repeat qualifying test is evaluated by the treating practitioner between the 61st and 90th day after oxygen starts, and a new written order is signed. Group I has no formal retest requirement, but continued need should stay documented.
New rental period
Breaks in need & replacement
In the first 36 months, if oxygen stops for more than 60 days plus the rest of that month and new medical necessity is established, a new 36-month rental period begins. A new order is also needed when equipment is replaced or changed.
Forms
No CMN 484, no prior authorization
Medicare eliminated the oxygen Certificate of Medical Necessity (CMN 484) starting with dates of service on January 1, 2023; the medical record and order now carry the documentation. Home oxygen isn’t on Medicare’s DMEPOS Required Prior Authorization List.
Medicare Advantage and New Mexico Medicaid (Turquoise Care) plans may have their own rules, including prior authorization. Please confirm with the patient’s plan. Medicare also requires the ordering practitioner to be enrolled in Medicare; our Medicare enrollment is in progress, so please call to confirm before sending a Medicare oxygen order request.
What to send us (recertification or new order)
Patient name and date of birth (through a secure channel only)
The current oxygen order
The most recent qualifying test report: date, result, conditions (rest, exercise, or sleep), whether on room air or oxygen, and who performed it
Equipment, liter flow, and hours of use (stationary, portable, or both)
Insurance (Medicare, Medicare Advantage, Turquoise Care, or other)
The date oxygen started and the due date (for example, the end of the 61st–90th day window)
The patient’s other treating clinicians, if known
Timing
We review requests during practice hours (Mon–Fri, 3:00–7:00 PM MT, or by appointment) and work to have the visit and paperwork done before the due date. For a Group II or III retest, please send the request as soon as the patient starts oxygen, so the repeat test can be scheduled inside the 61st–90th day window.
Until the secure link is live, call 505-977-9174 and we’ll set up a secure way to receive records.
Please do not send patient information by email. Use the secure request option or call 505-977-9174.
Patient choice, no payment for referrals. Patients choose their own oxygen supplier. We do not offer or accept payment or anything of value in exchange for referrals, orders, or testing, and we don’t accept tests performed or paid for by a supplier.
What to expect
What happens after a referral
Every referral follows the same steps, whoever sends it.
We review the referral
We confirm eligibility (adult, located in New Mexico, appropriate for telehealth) and check insurance. Referrals are reviewed during practice hours (Mon–Fri, 3:00–7:00 PM MT).
We contact the patient
We reach out to the patient or caregiver by phone. For transitional care after discharge, Medicare requires this contact within 2 business days of discharge.
We schedule the telehealth visit
A secure video or phone visit is set up. For transitional care, Medicare requires the visit within 7 or 14 days of discharge depending on complexity, with a medication review by the visit.
We coordinate with the referrer
With the patient’s care in mind, we share what’s needed through secure channels: visit documentation, orders when clinically appropriate, and follow-up needs. The patient’s other clinicians stay in the loop.
Ongoing care, if needed
Some patients continue with us for chronic disease or cardiometabolic care. Others return to their primary care clinician.
Good fit for referral
Adults 18+ physically located in New Mexico at each visit
Follow-up after a hospital, observation, SNF, rehab, or long-term acute care stay
Home oxygen orders and recertification, and other equipment documentation
Chronic disease and cardiometabolic care (blood pressure, diabetes, cholesterol, weight)
Not a fit
Emergencies or urgent same-day needs: call 911
Behavioral health care
Patients under 18 or located outside New Mexico
Care that requires an in-person exam or procedure
Patient choice. Patients may choose any clinician and any equipment supplier. We do not offer or accept payment or anything of value in exchange for referrals.
Insurance. We’re currently completing enrollment with Medicare and New Mexico health plans. Please call to confirm coverage before referring.
If you are having a medical emergency, call 911 or go to the nearest emergency room. This practice does not provide emergency care.
For referral partners
Medicare policy references
CMS MLN908628, Transitional Care Management Services: cms.gov