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HOUSE BILL 402
57
TH LEGISLATURE
-
STATE
OF
NEW
MEXICO
-
FIRST SESSION
,
2025
INTRODUCED BY
Joshua N. Hernandez
AN ACT
RELATING TO INSURANCE; REQUIRING THE SUPERINTENDENT OF
INSURANCE TO PROMULGATE RULES ESTABLISHING A TIME FRAME FOR
HEALTH INSURANCE CARRIERS TO LOAD INFORMATION ON APPROVED
PROVIDERS INTO THEIR PROVIDER PAYMENT SYSTEMS; REQUIRING HEALTH
INSURANCE CARRIERS TO REIMBURSE APPROVED PROVIDERS IF THE
HEALTH INSURANCE CARRIERS FAIL TO LOAD THAT INFORMATION WITHIN
THIRTY DAYS OF RECEIVING A COMPLETE CREDENTIALING APPLICATION.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
SECTION 1. A new section of the Short-Term Health Plan
and Excepted Benefit Act is enacted to read:
"[NEW MATERIAL] DENTAL PLAN--PROVIDER CREDENTIALING--
REQUIREMENTS--DEADLINE.--
A. The superintendent shall adopt and promulgate
rules to provide for a uniform and efficient provider
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credentialing process. The superintendent shall approve no
more than two forms of application to be used for the
credentialing of providers.
B. A health insurance carrier shall not require a
provider to submit information not required by a credentialing
application established pursuant to Subsection A of this
section.
C. The provisions of this section apply equally to
initial credentialing applications and applications for
recredentialing.
D. The rules that the superintendent adopts and
promulgates shall require primary credential verification no
more frequently than every three years and allow provisional
credentialing for a period of one year.
E. Nothing in this section shall be construed to
require a health insurance carrier to credential or
provisionally credential a provider.
F. The rules that the superintendent adopts and
promulgates shall establish that a health insurance carrier or
a health insurance carrier's agent shall:
(1) assess and verify the qualifications of a
provider applying to become a participating provider within
thirty calendar days of receipt of a complete credentialing
application and issue a decision in writing to the applicant
approving or denying the credentialing application;
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(2) be permitted to extend the credentialing
period to assess and issue a determination by an additional
fifteen calendar days if, upon review of a complete
application, it is determined that the circumstance presented,
including an admission of sanctions by the state licensing
board, an investigation or a felony conviction, a revocation of
clinical privileges or a denial of insurance coverage, requires
additional consideration;
(3) within ten working days after receipt of a
credentialing application, send a written notification, via
United States certified mail, to the applicant requesting any
information or supporting documentation that the health
insurance carrier requires to approve or deny the credentialing
application. The notice to the applicant shall include a
complete and detailed description of all of the information or
supporting documentation required and the name, address and
telephone number of a person who serves as the applicant's
point of contact for completing the credentialing application
process. Any information required pursuant to this section
shall be reasonably related to the information in the
application; and
(4) no later than thirty calendar days as
described in Paragraph (1) of this subsection or an additional
fifteen days as described in Paragraph (2) of this subsection,
load into the health insurance carrier's provider payment
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system all provider information, including all information
needed to correctly reimburse a newly approved provider
according to the provider's contract. The health insurance
carrier or health insurance carrier's agent shall add the
approved provider's data to the provider directory upon loading
the provider's information into the health insurance carrier's
provider payment system.
G. A health insurance carrier shall reimburse a
provider for covered health care services for any claims from
the provider that the health insurance carrier receives with a
date of service more than thirty calendar days after the date
on which the health insurance carrier received a complete
credentialing application for that provider if:
(1) the provider:
(a) has submitted a complete
credentialing application and any supporting documentation that
the health insurance carrier has requested in writing within
the time frame established in Paragraph (3) of Subsection F of
this section;
(b) 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
(c) has professional liability insurance
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or is covered under the Medical Malpractice Act; and
(2) the health insurance carrier:
(a) has approved, or has failed to
approve or deny, the applicant's complete credentialing
application within the time frame established pursuant to
Paragraph (1) or (2) of Subsection F of this section; or
(b) fails to load the approved
applicant's information into the health insurance carrier's
provider payment system in accordance with Paragraph (4) of
Subsection F of this section.
H. A provider who, at the time services were
rendered, was not employed by a practice or group that has
contracted with the health insurance carrier to provide
services at specified rates of reimbursement shall be paid by
the health insurance carrier in accordance with the health
insurance carrier's standard reimbursement rate.
I. A provider who, at the time services were
rendered, was employed by a practice or group that has
contracted with the health insurance carrier to provide
services at specified rates of reimbursement shall be paid by
the health insurance carrier in accordance with the terms of
that contract.
J. The superintendent shall adopt and promulgate
rules to provide for the resolution of disputes relating to
reimbursement and credentialing arising in cases where
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credentialing is delayed beyond thirty days after application.
K. A health insurance carrier shall reimburse a
provider pursuant to Subsections G, H and I of this section
until the earlier of the following occurs:
(1) the health insurance carrier's approval or
denial of the provider's complete credentialing application; or
(2) the passage of three years from the date
the health insurance carrier received the provider's complete
credentialing application.
L. As used in this section:
(1) "credentialing" means the process of
obtaining and verifying information about a provider and
evaluating that provider when that provider seeks to become a
participating provider; and
(2) "provider" means a person who has
graduated and received a degree from a school of dentistry that
is accredited by the commission on dental accreditation and
holds a license to practice dentistry in New Mexico."
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