TITLE 13 INSURANCE
CHAPTER 10 HEALTH INSURANCE
PART 28 PROVIDER PAYMENT
AND PROVIDER CREDENTIALING REQUIREMENTS
13.10.28.1 ISSUING AGENCY: Office of Superintendent of Insurance (OSI),
Life and Health (L&H)
[13.10.28.1
NMAC - N, 01/01/17]
13.10.28.2 SCOPE:
A. Applicability. This rule applies to all health carriers,
including health maintenance organizations, individual health plans, group and
blanket plans, provider service networks, non-profit healthcare plans and third-party
payers or their agents that provide, offer or administer health benefit plans,
including health benefit plans and managed health care plans subject to the
insurance laws and regulations of this state.
This rule also applies to all health care providers who are licensed to
provide health-related services in this state.
B. Timely
Payments. This rule addresses the timely
payment to providers by health carriers for covered services that have been
provided to the carrier’s enrollees or covered persons, the credentialing
process by which health carriers review and select providers who apply to join
carriers’ networks, and a dispute resolution process to be utilized by
providers and health carriers to resolve differences pertaining to provider
credentialing and payment for covered services.
C. Exclusions. This rule does not impose any requirement on
health carriers as to which providers must be accepted into health carriers’
networks, specify terms of contracts established between health carriers and
providers, establish standard reimbursement rates for payment by health
carriers to in- or out-of-network providers for services, or interpret terms of
any contract established between a health carrier and its enrollees or covered
persons.
[13.10.28.2
NMAC - N, 01/01/17]
13.10.28.3 STATUTORY AUTHORITY: Sections 59A-16-20; 59A-16-21.1, 59A-22-54,
59A-23-14, 59A-46-54, and 59A-47-48 NMSA 1978.
[13.10.28.3
NMAC - N, 01/01/17]
13.10.28.4 DURATION: Permanent.
[13.10.28.4
NMAC - N, 01/01/17]
13.10.28.5 EFFECTIVE DATE: January 1, 2017, unless a later date is cited
at the end of a section.
[13.10.28.5
NMAC - N, 01/01/17]
13.10.28.6 OBJECTIVE: The purpose of this rule is to establish a
uniform and efficient provider credentialing process and to ensure that
providers receive prompt payment from health carriers for clean claims and
interest on unpaid claims. This rule
also establishes a process for resolving payment-related credentialing disputes
between health carriers and providers.
[13.10.28.6
NMAC - N, 01/01/17]
13.10.28.7 DEFINITIONS: As used in this rule:
A. “Business day”
means a consecutive 24-hour period, excluding weekends or holidays.
B. “Claim” means a
request from a provider for payment for health care services.
C. “Clean claim”
means a manually or electronically submitted claim from an eligible provider
that:
(1) contains substantially all the required data elements
necessary for accurate adjudication without the need for additional information
from outside of the health carrier’s system;
(2) is not materially deficient or improper, including lacking
substantiating documentation currently required by the health carrier; and
(3) has no particular or unusual circumstances requiring special
treatment – such as, but not limited to, coordination of benefits, pre-existing
conditions, subrogation, or suspected fraud – that prevents payment from being
made by the health carrier within 30 days of the date of receipt if submitted
electronically or 45 days if submitted manually.
D. “Completed
credentialing application” means a credentialing application that is free
of defects and contains all of the information that, when later supplemented by
verifications and documentation gathered by the health carrier during the
primary source verification process, is necessary for the health carrier to
make a credentialing decision.
E. “Covered benefits” means the
specific health services provided under a health benefits plan.
F. “Credentialing” means the
process of obtaining and verifying information about a provider and evaluating
that provider when that provider applies to become a participating provider
within a health carrier’s network.
G. “Credentialing application” means the
application form to be used for the credentialing of providers.
H. “Credentialing intermediary” means a person
to whom a health carrier has delegated credentialing or re-credentialing
authority and responsibility.
I. “Date of receipt” means the date
on which a claim or credentialing application is deemed received, as follows:
(1) for claims and
credentialing applications submitted electronically or sent via fax and unless
the sender is notified immediately of a transmission error, the date of receipt
is the date on which a claim or credentialing application is submitted or, for
claims that arrive on a non-business day, the date of the first business day
thereafter;
(2) for
claims and credentialing applications that are hand delivered, the date of
receipt is the date of delivery; or
(3) for
claims and credentialing applications submitted through the US mail, the health
carrier may select and shall consistently administer one of the following
options:
(a) the
first business day following the date of actual receipt by a person or
organization that has been designated by the health carrier to manage incoming
mail;
(b) if no person or
organization has been designated to manage incoming mail, then the first business
day following the date of actual receipt by the health carrier; or
(c) three
business days after the postmark on the claim or application that is submitted
through the US mail.
J. “Day” means a calendar day, including
weekends, holidays, and any other non-business days.
K. “Electronic claim submission” means a request
for payment that is submitted by a provider to a health carrier via an
electronic portal or using another on-line form or submission process that
complies with state and federal patient privacy protection requirements and
links or transmits directly to the health carrier.
L. “Enrollee or covered person” means an
individual who is entitled to receive health care benefits provided by a health
carrier for covered health-related services, subject to out-of-network costs,
deductibles, co-payments, co-insurance deductibles or other cost-sharing
provisions provided by the health benefits plan.
M. “Health benefits plan” means a policy,
contract, certificate or agreement entered into, offered or issued by a health
carrier to provide, deliver, arrange for, pay for or reimburse any of the costs
of health care services.
N. “Health care professional” means an
individual engaged in the delivery of health care services that is licensed or
authorized to practice in this state.
O. “Health care services” means services,
supplies, and procedures for the diagnosis, prevention, treatments, cure or
relief of a health condition, illness, injury, or disease, and includes, to the
extent offered by the health benefits plan, physical and mental health
services, including community-based mental health services, and services for
developmental disability or developmental delay.
P. “Health insurer or health carrier”
means an entity subject to the insurance laws and regulations of this state,
including a health insurance company, a health carrier, a health maintenance
organization, a hospital and health service corporation, a provider service
network, a non-profit health care plan, a third-party, or any other entity that
contracts or offers to contract, or enters into agreements to provide, deliver,
arrange for, pay for or reimburse any costs of health care services, or that
provides, offers or administers health benefit policies and managed health care
plans in this state.
Q. “Manual claim submission” means a request
for payment that is submitted by a provider to a health carrier via US mail,
fax, e-mail, or hand delivery.
R. “Network” means the group(s) of
participating providers who provide services under a network plan or managed
health care plan.
S. “Network plan” means a health
benefits plan that either requires a covered person to use, or creates
incentives, including financial incentives, for a covered person to use health
care providers managed, owned, under contract with or employed by the health
carrier.
T. “Participating provider” means a
provider, health care professional, or facility who under express contract with
a health carrier or with its contractor or subcontractor, has agreed to provide
health care services to enrollees with an expectation of receiving payment
directly or indirectly from the health carrier, subject to co-payments,
co-insurance deductibles, or other cost-sharing provisions.
U. “Provider” means a physician, hospital or
other health care professional licensed or otherwise authorized to furnish
health care services in this state.
V. “Practice group” means an
incorporation or other legal collaboration of providers who work together
sharing responsibility for providing care, liability and resources.
W. “Provisional acceptance” means a
provider that is treated by a health carrier as a participating provider for a
period of up to one-year, based on the results of credentialing.
X. “Standard reimbursement rate” means the
usual, customary and reasonable reimbursement rate paid to providers for health
care services that is at or near the median rate paid for similar health care
services within the surrounding geographic area where the charges were
incurred.
Y. “Superintendent” means the
superintendent of insurance, acting on behalf of the office of the
superintendent, or anyone acting in an official capacity on the
superintendent’s behalf.
Z. “Uniform credentialing forms” means the
version current at the time of the application or re-application process of
forms used by the hospital services corporation (HSC), the counsel for
affordable quality healthcare datasource (CAQH), or
another form as approved by the superintendent provided that the form is used
only for the credentialing of facility and ancillary providers, or other
credentialing forms as specified by a bulletin posted on the OSI website,
including any revisions thereto and as developed and updated from time to time
and including electronic versions of such forms.
AA. “Verification or verification
supporting statement” means documentation confirming the
information submitted by an applicant for credentialing by a specifically named
entity or by a regional, national, or general data depository providing primary
source verification, including but not limited to a college, university,
medical school, teaching hospital, specialty certification board, health care
facility or institution, state licensing board, federal agency or department,
professional liability insurer, or the national practitioner data bank.
[13.10.28.7
NMAC - N, 01/01/17]
13.10.28.8 CLAIM SUBMISSION AND CODING
CHANGES:
A. General.
(1) Health
carriers shall comply with both the provisions of this section and with the
provisions of 13.10.12 NMAC, which provides for standardization of health claim
forms.
(2) Claims
information, including claim status information shall be subject to state and
federal patient privacy protection laws.
(3) A
health carrier that has entered into a contract with one or more intermediaries
to conduct provider credentialing or provide payments to providers shall
require the intermediary to indicate the name of the intermediary and the name
of the health carrier for which it is conducting the work when contacting a provider
on behalf of the health carrier.
B. Electronic submission.
(1) Health
carriers shall make available to participating providers a process and
procedure for submitting claims electronically.
(2) Health
carriers shall make available to participating providers a process and
procedure for electronically making coding changes for claims after submission.
(3) Claims
that are transmitted electronically are deemed to be received by the health
carrier on the date of receipt unless the provider receives immediate notice of
a transmission error.
(4) When
a claim is submitted electronically and the health carrier subsequently
determines that there is an error or omission with the submission that will
delay or prevent payment to the participating provider, the health carrier
shall make a good faith effort to notify the participating provider by fax,
electronic, or other written communication within 30 days following the date of
receipt.
(5) Any
notification from a health carrier to a provider that there is an error or
omission in a claim submission must contain a specific statement regarding all
information sought to rectify the error or omission. The carrier shall make a good faith effort to
convey all of the errors or omissions to the provider at one time. A pattern of repetitive requests for the same
information from a health carrier to a provider is a violation of Article 16 of
the Insurance Code, as defined at §59A-16-20.
C. Manual submission.
(1) Health carriers
shall make standard forms available to providers for submitting claims manually
via US mail, fax, e-mail, or hand delivery.
(2) Health carriers
shall make standard forms available to providers for manual coding changes to
be submitted via US mail, fax, e-mail, or hand delivery.
(3) Claims that are
submitted via US mail are deemed to be received by the health carrier on the
date of receipt. Claims that are
transmitted via fax, E-mail or hand delivery are deemed to be received by the
health carrier on the date of receipt unless the provider receives immediate
notice of a transmission error.
(4) When a claim is
submitted manually and the health carrier subsequently determines that there is
an error or omission with the submission that will delay or prevent payment to
the provider, the health carrier shall make a good faith effort to notify the
participating provider in writing within 45 days following the date of receipt.
(5) Any notification
from a health carrier to a provider that there is an error or omission in a
claim submission must contain a specific statement regarding all information
sought to rectify the error or omission.
The carrier shall make a good faith effort to convey all of the errors
or omissions to the provider at one time.
A pattern of repetitive requests for the same information from a health
carrier to a provider is violation of Article 16 of the Insurance Code, as
defined at §59A-16-20.
D. Access to Claims Status Information.
(1) Health carriers
shall provide an electronic means whereby participating providers can access
claim information within three business days of the date of receipt for
electronic claims and within 10 business days of the date of receipt for manual
claims.
(2) The information
that is available to the provider shall indicate the status of the request for
payment, including, but not limited to the following:
(a) date of
receipt;
(b) identifying
claim information, which may include enrollee/covered persons identifiers,
date(s) of service, and appropriate coding, as required by the health carrier
and agreed to by the provider;
(c) whether the
claim is pending or if it has been accepted or rejected for payment;
(d) if the
claim is pending, whether the health carrier has requested additional
information from the provider to complete processing of the claim;
(e) if the
claim has been accepted, the payment amount that has been approved; and
(f) a
clear explanation of the circumstances if the claim has been found to involve
particular or unusual circumstances that require special treatment and that are
likely to delay payment.
[13.10.28.8
NMAC - N, 01/01/17]
13.10.28.9 PAYMENT OF CLAIMS, OVERDUE CLAIMS
AND CALCULATION OF INTEREST:
A. Payment of claims - timeliness.
(1) Claim
payment. Health carriers shall promptly
pay providers upon receipt of clean claims for uncontested covered health care
services that the provider has supplied.
(2) Timeliness. The health carrier shall reimburse the
eligible provider within 30 days of the date of receipt if the clean claim has
been submitted electronically or within 45 days of the date of receipt if the
clean claim has been submitted manually.
(3) Prompt
payment. For purposes of prompt payment,
a claim shall be deemed to have been “paid” upon one of the following:
(a) a check is mailed by the health carrier or its intermediary
to the provider; or
(b) an electronic transfer of funds is made by the health
carrier or its intermediary to the provider.
(4) Reimbursement
rate. The health carrier shall make
payment to the provider based on the standard reimbursement rate as specified
within the contractual agreement, or as otherwise agreed upon between the
health carrier and the provider.
(5) Multi-claim
payments. A single payment made to a
provider can serve as payment for multiple claims, but must clearly identify
each claim and the amount of the claim that has been satisfied by the payment. If non-claim payments to a provider are
included in a multi-claim payment, the nature of those payments must also be
clearly identified.
B. Interest on unpaid clean claims. A health carrier shall pay interest as set
forth in Subsection D of 13.10.28.9 NMAC on the amount of any clean claim that
has not been paid within the time specified in Subsection A of 13.10.28.9 NMAC.
C. Pending claims.
(1) Questionable
liability and special treatment claims.
(a) If,
upon receipt of a claim, a health carrier is unable to determine liability for,
or otherwise refuses to pay a claim or a portion of a claim of an eligible
provider within the time specified in Subsection A of 13.10.28.9 NMAC, the
health carrier shall make a good faith effort to notify the eligible provider
electronically, in writing, or by another method, as agreed between the health
carrier and provider, within 30 days of
the date of receipt of the claim if submitted electronically and within 45 days
of the date of receipt of the claim if submitted manually.
(b) If,
upon receipt of a claim, a health carrier determines that a claim or a portion
of a claim requires special treatment due to particular or unusual
circumstances that will delay payment beyond the time specified in Subsection A
of 13.10.28.9 NMAC, the health carrier shall make a good faith effort to notify
the eligible provider electronically, in writing, or by another method, as
agreed between the health carrier and provider, within 30 days of the date of
receipt of the claim if submitted electronically and within 45 days of the date
of receipt of the claim if submitted manually.
(2) Notification
of pending claims. The notification
required by Subsection C of 13.10.28.9 NMAC, shall:
(a) specify the reason(s) why the health carrier is refusing to
pay the claim, has determined it is not liable for the claim, or shall specify
what information is required to determine liability for the claim;
(b) clearly indicate if only certain charges associated with a
claim are contested; and
(c) shall be repeated by the health carrier at least monthly
until the matter is resolved.
(3) Uncontested
portion of pending claims. The timely
payment requirement described in Section A of 13.10.28.9 NMAC applies to any
uncontested portion of a contested claim.
(4) Liability
resolved. The date on which liability or
special treatment issues are resolved for a pending claim is the date that the
claim becomes a clean claim and shall initiate the timely payment requirement
described in Subsection A of 13.10.28.9 NMAC.
D. Overdue payments, calculation of interest.
(1) When
payment is not made by the health carrier to the provider within the time
specified in Subsection A of 13.10.28.9 NMAC and there is no question of
liability or special treatment as described in Subsection C of 13.10.28.9 NMAC
or questions of liability or special treatment have been resolved, interest
shall be calculated and paid to the provider, on the unpaid portion of the
claim as follows:
(a) For
any full or partial month, beginning on the 31st day after the claim has been
submitted electronically and on the 46th day for claims submitted manually, the
health carrier shall calculate and pay interest in the amount of one and
one-half percent for each full or partial month. For purposes of this section, any 30-day
period is the equivalent of one month, excepting that a calendar year shall
only be equal to 12 months; and
(b) Interest
shall be calculated beginning the day after the required payment date and
ending on the date the claim is paid.
The health carrier shall not be required to pay any interest calculated
to be less than two dollars ($2.00). The
interest shall be paid within 30 days of the payment of the claim. Interest can be paid on the same check or
electronic transfer as the claim payment or on a separate check or electronic
transfer. If the health carrier combines
interest payments for more than one late clean claim, the check or electronic
transfer shall include information identifying each claim covered by the check
or electronic transfer and the specific amount of interest being paid for each
claim.
(2) When
a claim that involves a question of liability or special treatment is
ultimately resolved in favor of the provider and is not paid within 30 or 45
days of becoming an electronic or manual clean claim, respectively, the health
carrier shall pay all of the interest due on the unpaid claim, to be calculated
as described in Paragraph (1) of Subsection D of 13.10.28.9 NMAC.
[13.10.28.9
NMAC - N, 01/01/17]
13.10.28.10 GENERAL PROVIDER CREDENTIALING: The provisions of this section apply equally
to initial credentialing applications and applications for re-credentialing.
A. Credential verification program.
(1) In
order to ensure accessibility and availability of services, each health carrier
shall establish a program in accordance with this regulation that verifies that
its participating providers are credentialed before the health carrier accepts
a provider into its network and lists a provider in the health carrier’s
provider directory, handbooks, or other marketing or member materials.
(2) The
credential verification program established by each health carrier shall
provide for an identifiable person(s) to be responsible for all credential
verification activities, which person(s) shall be capable of carrying out that
responsibility.
(3) A
health carrier is not obligated to approve all applications for credentialing
and may deny any application based on existing network adequacy, issues with an
application, failure by provider to provide a complete credentialing
application, or another reason.
(4) No
contract between a health carrier and a participating provider shall include a
clause that has the effect of relieving either party of liability for its
actions or inactions.
B. Delegation of credential verification activities.
(1) Whenever
a health carrier delegates credential verification activities to a contracting
entity, whether a credentialing intermediary or subcontractor, the health
carrier shall review and approve the contracting entity’s credential
verification program before contracting and shall require that the entity
comply with all applicable requirements of this regulation.
(2) The
health carrier shall monitor the contracting entity’s credential certification
activities.
(3) The health
carrier shall implement oversight mechanisms, including:
(a) reviewing the
contracting entity’s credential verification plans, policies, procedures,
forms, and adherence to verification procedures; and
(b) conducting an
evaluation of the contracting entity’s credential verification program at least
every two years.
(4) The health
carrier’s monitoring activities should at least meet the verification
procedures and standards as defined by the national committee for quality assistance
(NCQA).
C. Written credential verification plan.
(1) Each health
carrier shall develop and adopt a written credentialing plan that contains
policies and procedures to support the credentialing verification program.
(2) Each health
carrier’s written credential verification plan shall:
(a) include the
purpose, goals, and objectives of the credential verification program;
(b) include
written criteria and procedures for initial enrollment, renewal, restrictions,
and termination of providers;
(c) be
provided to the superintendent upon request;
(d) provide an
organized system to manage and protect confidentiality of credentialing files
and records; and
(e) require that
records and documents relating to provider credentialing be retained for at
least six years.
(3) Each health
carrier’s credentialing verification plan shall include a process to assess and
verify the qualifications of providers applying to become participating
providers within 45 calendar days of receipt of a provider’s request for
credentialing or a provider’s completed uniform credentialing form, whichever
is earlier. The plan shall allow for the
following to take place within this 45 calendar days:
(a) time
required to obtain the completed uniform credentialing form in electronic
format, if necessary;
(b) time to
request and obtain primary source verifications and other information that must
be obtained from third parties in order to authenticate the applicant’s
credentials;
(c) a
final decision by a credentialing committee if the health carrier’s plan
requires such review; and
(d) time to
notify the provider of the health carrier’s decision.
D. Reporting requirements. Each health carrier shall submit a report to
the superintendent regarding its credentialing process for the prior two-year
period beginning December 31, 2018, and on December 31 for all even numbered
years thereafter, or as otherwise directed by the superintendent. The report shall include the following:
(1) the
number of applications made to the plan for each type of provider;
(2) the
number of applications approved by the plan for each type of provider;
(3) the
number of applications rejected by the plan for each type of provider;
(4) the
number of providers terminated for reasons of quality; and
(5) the
amount of time taken to review and reach a determination on an application.
E. Use of uniform credentialing forms required:
(1) Beginning January
1, 2017, a health carrier shall not use any provider credentialing application
form other than uniform credentialing forms, as that term is defined in
13.10.28.7 NMAC.
(2) Should the
superintendent determine that these forms no longer represent industry
standards; the superintendent will issue a bulletin advising of alternative
credentialing forms to be used to satisfy this requirement.
(3) A health carrier
or its credentialing or re-credentialing intermediary shall make uniform
credentialing application forms available to any health care provider that
seeks to be credentialed or re-credentialed by that health carrier or its
credentialing intermediary and also accept uniform credentialing applications
electronically or through electronic transfer upon the request of any provider.
(4) An exception to
Paragraph (1) of Subsection E of 13.10.28.10 NMAC is made for providers who:
(a) are
licensed and also practice outside of New Mexico; and
(b) prefer to
use the credentialing forms required by their respective states. In such circumstances, the health carrier and
its delegated entity, if any, may accept those forms.
F. Required information. A health carrier shall not require an
applicant to submit information not required by the uniform credentialing or
re-credentialing forms other than information or documentation that is
reasonably related to information on the application.
G. Accreditation by nationally recognized accrediting
entity.
(1) Nothing in this
section shall require a health carrier to violate or fail to meet a standard or
requirement of a nationally recognized accrediting entity.
(2) A health carrier
may seek a waiver of these requirements from the superintendent by submitting
accreditation by a nationally recognized entity as evidence of compliance with
the requirements of this section.
(3) In those
instances where a health carrier seeks to meet the requirements of this section
through accreditation by a private accrediting entity, the health carrier shall
submit to the superintendent the following information:
(a) current
standards of the private accrediting entity in order to demonstrate that the
entity’s standards meet or exceed the requirements of this rule;
(b) documentation from
the private accrediting entity showing that the health carrier has been
accredited by the entity; and
(c) a
summary of the data and information that was presented to the private
accrediting entity by the health carrier and upon which accreditation of the
health carrier was based.
(4) A health carrier
accredited by the private accrediting entity that has submitted all of the
requisite information to the superintendent may then be determined by the
superintendent to have met the requirements of the relevant provisions of this
section where comparable standards exist, provided that the private accrediting
entity from which the health carrier obtained accreditation is recognized and
approved by the superintendent.
[13.10.28.10
NMAC - N, 01/01/17]
13.10.28.11 TIMELY CREDENTIALING DECISIONS:
A. Initiation of credentialing process. The credentialing process may be initiated by
a provider, who either:
(1) provides a
completed uniform credentialing form directly to the health carrier; or
(2) notifies the
health carrier that the provider is requesting credentialing by the health
carrier, that the provider’s completed uniform credentialing form is in
electronic format and is available to the health carrier for access via the
credentialing form’s website or on-line database, and that the health carrier
is requested to obtain the provider’s completed uniform credentialing form.
B. Initial verification upon receipt.
(1) Upon receiving a
provider’s request for credentialing or a provider’s completed credentialing
form, a health carrier or a health carrier’s agent shall review the application
to verify that the application includes all necessary information and
documentation that is reasonably related to the information in the
application. The health carrier may
initially attempt to obtain additional or missing information by informal means
including but not limited to fax, telephone, or e-mail.
(2) A health carrier
or a health carrier’s agent shall notify the applicant by US certified mail
within 10 days of receipt that the request for credentialing has been received,
but that if the application is incomplete that the 45-day time period set forth
in Subsection C of 13.10.28.11 NMAC shall not commence until the applicant
provides all requested information or documentation.
(3) Any request for
additional information that has not been met through an informal exchange and
remains outstanding at the end of the initial 10-day review period shall also
be sent to the provider via the same or separate certified mail within 10
business days of receipt of the application, to include:
(a) a
complete and detailed description of all of the information or supporting
documentation that is reasonably related to information in the application that
the insurer requires to approve or reject the credentialing application; and
(b) the
name, address, e-mail, and telephone number of a person who serves as the
applicant’s point of contact for completing the credentialing application
process; and
(c) notice that
if an application remains incomplete and the applicant has been unresponsive to
requests for information beyond 45 days, then the health carrier may deny the
application for failure to respond and notify the applicant that the
application is denied.
C. Timely decision.
(1) Within 45
calendar days of the date of receipt of a request for credentialing, the health
carrier or the health carrier’s agent shall:
(a) assess and
verify the qualifications of a provider applying to become a participating
provider; and
(b) review the
application and determine whether to approve or deny the credentialing
application.
(2) The
health carrier may:
(a) approve the provider for the health carrier’s network for a
period of up to three years;
(b) provisionally
accept the provider for the health carrier’s network for a period of one-year,
or the maximum duration up to one-year as allowed by the health carrier’s
accreditation organization; or
(c) deny the provider for the health carrier’s network.
(3) The
health carrier’s decision must be issued to the provider in writing by US mail
at the
physical or mailing
address listed in the application, and
by e-mail if an e-mail address has been provided.
D. Timing for re-credentialing.
(1) If
the credentialing application is approved, re-credentialing verification may
not be required more frequently than every three years.
(2) If
the application is approved provisionally, then re-credentialing shall be
required annually or at the conclusion of the shorter period if required by a
health carrier’s accreditation organization and approved by the superintendent.
(3) Nothing
in this section shall be construed to require a health carrier to credential or
provisionally credential any provider.
(4) Nothing
in this section shall be construed to prevent a health carrier from terminating
its participation agreement with a provider for cause at any time; regardless
of time remaining before re-credentialing is due.
(5) Except
as may otherwise be required by a health carrier’s accreditation organization a
health carrier may not require a participating provider to be re-credentialed
based on:
(a) a change in the provider’s federal tax identification
number;
(b) a change in the federal tax identification number of a
provider’s employer; or
(c) a change in the provider’s employer, if the new employer:
(i) is a
participating provider; or
(ii) also
employs other participating providers.
(6) A health carrier
may require that a participating provider or the provider’s employer give
written notice to the health carrier of a change in the provider’s or the
provider’s employer’s federal tax identification number not less than 45
calendar days before the effective date of the change.
E. Accreditation by nationally recognized accrediting entity.
(1) A health carrier
may seek a waiver of these credentialing requirements from the superintendent
by submitting accreditation by a nationally recognized entity as evidence of
compliance with the requirements of this section.
(2) In those
instances where a health carrier seeks to meet the requirements of this section
through accreditation by a private accrediting entity, the health carrier shall
submit to the superintendent the following information:
(a) current standards of the private accrediting entity in order
to demonstrate that the entity’s standards meet or exceed the requirements of
this rule;
(b) documentation
from the private accrediting entity showing that the health carrier has been
accredited by the entity; and
(c) a
summary of the data and information that was presented to the private
accrediting entity by the health carrier and upon which accreditation of the
health carrier was based.
(3) The
superintendent will determine whether a health carrier that has been accredited
by a private accrediting entity and has submitted all of the requisite
information has met the requirements of the relevant provisions of this section
where comparable standards exist.
[13.10.28.11
NMAC - N, 01/01/17]
13.10.28.12 REIMBURSEMENT BY HEALTH CARRIER UPON
DELAY IN CREDENTIALING PROCESS:
A. Terms for reimbursement. A health carrier shall reimburse a provider,
subject to co-payments, co-insurance, deductibles, or other cost-sharing
provisions, for any clean claims for covered services, provided that:
(1) the
date of service is more than 45 calendar days after the date the provider
requested credentialing from the health carrier and either the provider
supplied a completed uniform credentialing application or made the completed
uniform credentialing application available for electronic access by the health
carrier, including submission of any supporting documentation that the health
carrier requested in writing during the initial 10-day review period;
(2) the
health carrier has approved, or has failed to approve or deny the applicant’s
completed uniform credentialing application within the timeframe established
pursuant to Subsection C of 13.10.28.11 NMAC;
(3) the
provider has no past or current license sanctions or limitations, as reported
by the New Mexico medical board or another pertinent licensing and regulatory
agency, or by a similar out-of-state licensing and regulatory entity for a
provider licensed in another state; and
(4) the provider has professional liability insurance or is
covered under the Medical Malpractice Act.
B. Sole practitioner. A provider who, at the time services were
rendered has been approved by a health carrier for credentialing or who has
been awaiting a credentialing decision pursuant to Subsection C of 13.10.28.11
NMAC and was not in a practice or group that has contracted with the health
carrier to provide services at specified rates of reimbursement, shall be paid
by the health carrier in accordance with the carrier’s standard reimbursement
rate or at an agreed upon rate.
C. Provider group reimbursement. A provider who, at the time services were
rendered, has been approved by a health carrier for credentialing or who has
been awaiting a credentialing decision pursuant to Subsection C of 13.10.28.11
NMAC and was in a provider group that has contracted with the health carrier to
provide services at specified rates of reimbursement, shall be paid by the
carrier in accordance with the terms of the provider group contract.
D. Reimbursement period. A health carrier shall reimburse a provider
pursuant to Subsections A, B, and C of 13.10.28.12 NMAC until the earlier of
the following occurs:
(1) the health carrier denies the provider’s credentialing
application;
(2) the health carrier approves the provider’s credentialing
application and the provider and health carrier enter a contract to replace a
previously agreed upon rate, or
(3) the passage
of three years from the date the insurer received the provider’s completed
uniform credentialing application.
[13.10.28.12
NMAC - N, 01/01/17]
13.10.28.13 CREDENTIALING AND PAYMENT DISPUTE
RESOLUTION:
A. Internal review process.
(1) Each
health carrier shall establish an internal process for resolving disputes
regarding payment of claims between the health carrier and providers arising
when a credentialing decision is delayed beyond the timeline found in
Subsection C of 13.10.28.11 NMAC, the prompt payment deadline described in
Paragraph (2) of Subsection A of 13.10.28.9 NMAC has passed, and payment has
not been made.
(2) The
internal process shall include required notification regarding pending claims
and calculation and payment of interest on overdue claims, as described in
Subsections C and D of 13.10.28.9 NMAC.
(3) The
internal process shall provide for resolution of disputes regarding
reimbursement rates as described in 13.10.28.12 NMAC.
(4) At
a minimum, the internal review process shall provide for the following:
(a) To
initiate a payment dispute, the provider shall contact the health carrier in
writing to determine the status of a claim, to ensure that sufficient
documentation supporting the claim has been provided, and to determine whether
the claim is considered by the health carrier to be a clean claim.
(b) The
health carrier shall respond in writing to a provider’s inquiry regarding the
status of an unpaid claim within 15 days of receiving the inquiry.
(c) The
health carrier’s response shall explain its failure or refusal to pay, and the
expected date of payment if payment is pending.
(5) The
internal review process may provide specific procedures for resolving payment
disputes, including by not limited to, the use of medication.
B. Complaint filed with Superintendent.
(1) If
the health carrier fails to respond or the provider believes that payment is
being denied, delayed, or calculated in error and the matter has not been
successfully resolved at the internal level within 45 days, then the provider
may file a complaint, either individually or in batches, with the
superintendent using the form found on the OSI website.
(2) Complaints
filed with the superintendent shall contain the following information:
(a) the provider’s name, identification number, address, daytime
telephone number and the claim number;
(b) the date that the provider’s request for credentialing was
complete;
(c) the name and address of the health carrier;
(d) the name of the patient and employer (if known);
(e) the date(s) of service and the date(s) the claims were
submitted to the health carrier;
(f) relevant correspondence between the provider and the health
carrier, including requests for additional information from the health carrier;
(g) additional information which the provider believes would be
of assistance in the superintendent’s review; and
(h) only those excerpts from provider contracts that are
minimally necessary to resolve the dispute shall be submitted to the
superintendent, who shall maintain the confidentiality of such excerpts to the
fullest extent allowed by applicable law.
(3) The
complaining provider shall furnish the health carrier with a complete copy of
the complaint and submitted documentation concurrently with the provider’s
submission to the superintendent.
(4) The
health carrier shall be afforded 10 business days after the provider’s
submission to resolve the matter or to submit additional information that the
health carrier believes would be of assistance to the superintendent’s review.
(5) The
superintendent will review the matter, based on documents and other materials
that are submitted by the provider and health carrier for this purpose.
(6) The
superintendent may issue an order resolving the dispute, with or without a
hearing.
(7) If
the superintendent determines, at his sole discretion, that a hearing is
necessary, then the provider and the health carrier may appear and may elect to
be represented by counsel at the hearing.
(8) The
superintendent may designate one or more persons to act as hearing
officer. The hearing officer shall
prepare a recommendation for the superintendent’s review.
(9) The
superintendent’s decision will be issued within 30 days of receiving a payment
complaint if no hearing is required or within 30 days of the hearing, if a
hearing is held.
(10) The
superintendent may order a health carrier to reimburse a provider at the
standard reimbursement rate for covered services provided to the health
carrier’s enrollees, subject to out-of-network costs, deductibles, co-payments,
co-insurance or other cost-sharing provisions due from the enrollee.
(11) In
addition to any applicable suspension, revocation or refusal to continue any
certificate of authority or license under the insurance code, the
superintendent may find that violators of the regulations set forth in this
section are subject to the standard penalties for material violations of the
insurance code, in accordance with sections 59A-1-18 and 59A-46-25 NMSA 1978.
(12) The
provisions of this subsection do not prevent the superintendent from
investigating a complaint when the provider has failed to contact the health
carrier.
[13.10.28.13
NMAC - N, 01/01/17]
13.10.28.14 SEVERABILITY: If any section of this rule, or
the applicability of any section to any person or circumstance, is for any
reason held invalid by a court of competent jurisdiction, the remainder of the
rule, or the applicability of such provisions to other persons or
circumstances, shall not be affected.
[13.10.28.14
NMAC - N, 01/01/17]
HISTORY OF
13.10.28 NMAC: [RESERVED]