HGEIC/HB 402
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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
DENTISTS AND DENTAL HYGIENISTS INTO THEIR PROVIDER PAYMENT
SYSTEMS; REQUIRING HEALTH INSURANCE CARRIERS TO REIMBURSE
APPROVED DENTISTS AND DENTAL HYGIENISTS 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:
"DENTAL PLAN--PROVIDER CREDENTIALING--REQUIREMENTS--
DEADLINE.--
A. The superintendent shall adopt and promulgate
rules to provide for a uniform and efficient provider
credentialing process. The superintendent shall approve no
more than two forms of application to be used for the
credentialing of dentists and dental hygienists.
B. A health insurance carrier shall not require a
dentist or dental hygienist to submit information not
required by a credentialing application established pursuant
to Subsection A of this section. HGEIC/HB 402
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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 dentist or dental hygienist.
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 dentist or dental hygienist who is 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;
(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 HGEIC/HB 402
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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 system all dentist or dental hygienist information,
including all information needed to correctly reimburse a
newly approved dentist or dental hygienist according to the
dentist's or dental hygienist's contract. The health
insurance carrier or health insurance carrier's agent shall
add the approved dentist's or dental hygienist's data to the HGEIC/HB 402
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provider directory upon loading the dentist's or dental
hygienist's information into the health insurance carrier's
provider payment system.
G. A health insurance carrier shall reimburse a
dentist or dental hygienist for covered health care services
for any claims from the dentist or dental hygienist 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 dentist or dental hygienist if:
(1) the dentist or dental hygienist:
(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 board
of dental health care or another pertinent licensing and
regulatory agency or a similar out-of-state licensing and
regulatory entity for a dentist or dental hygienist who is
licensed in another state; and
(c) has professional liability
insurance or is covered under the Medical Malpractice Act;
and HGEIC/HB 402
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(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 dentist or dental hygienist 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 dentist or dental hygienist 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
credentialing is delayed beyond thirty days after HGEIC/HB 402
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application.
K. A health insurance carrier shall reimburse a
dentist or dental hygienist 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 dentist's or dental hygienist's complete
credentialing application; or
(2) the passage of three years from the date
the health insurance carrier received the dentist's or dental
hygienist's complete credentialing application.
L. As used in this section:
(1) "credentialing" means the process of
obtaining and verifying information about a dentist or dental
hygienist and evaluating that dentist or dental hygienist
when that dentist or dental hygienist seeks to become a
participating provider;
(2) "dental hygienist" means an individual
who has graduated and received a degree from a dental hygiene
educational program that is accredited by the commission on
dental accreditation, provides a minimum of two academic
years of dental hygiene curriculum and is an institution of
higher education; and "dental hygienist" means, except as the
context otherwise requires, an individual who holds a license
to practice dental hygiene in New Mexico; and
(3) "dentist" means a person who has HGEIC/HB 402
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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."