NM
New Mexico House Bill HB402

New Mexico 2025 Regular Session

New Mexico House Bill HB402 Compare Versions

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1-HGEIC/HB 402
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2+[bracketed material] = delete
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28+HOUSE BILL 402
29+57
30+TH LEGISLATURE
31+-
32+
33+STATE
34+
35+OF
36+
37+NEW
38+
39+MEXICO
40+
41+-
42+ FIRST SESSION
43+,
44+
45+2025
46+INTRODUCED BY
47+Joshua N. Hernandez
2848 AN ACT
2949 RELATING TO INSURANCE; REQUIRING THE SUPERINTENDENT OF
3050 INSURANCE TO PROMULGATE RULES ESTABLISHING A TIME FRAME FOR
3151 HEALTH INSURANCE CARRIERS TO LOAD INFORMATION ON APPROVED
32-DENTISTS AND DENTAL HYGIENISTS INTO THEIR PROVIDER PAYMENT
33-SYSTEMS; REQUIRING HEALTH INSURANCE CARRIERS TO REIMBURSE
34-APPROVED DENTISTS AND DENTAL HYGIENISTS IF THE HEALTH
35-INSURANCE CARRIERS FAIL TO LOAD THAT INFORMATION WITHIN
36-THIRTY DAYS OF RECEIVING A COMPLETE CREDENTIALING
37-APPLICATION.
52+PROVIDERS INTO THEIR PROVIDER PAYMENT SYSTEMS; REQUIRING HEALTH
53+INSURANCE CARRIERS TO REIMBURSE APPROVED PROVIDERS IF THE
54+HEALTH INSURANCE CARRIERS FAIL TO LOAD THAT INFORMATION WITHIN
55+THIRTY DAYS OF RECEIVING A COMPLETE CREDENTIALING APPLICATION.
3856 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
3957 SECTION 1. A new section of the Short-Term Health Plan
4058 and Excepted Benefit Act is enacted to read:
41-"DENTAL PLAN--PROVIDER CREDENTIALING--REQUIREMENTS--
42-DEADLINE.--
59+"[NEW MATERIAL] DENTAL PLAN--PROVIDER CREDENTIALING--
60+REQUIREMENTS--DEADLINE.--
4361 A. The superintendent shall adopt and promulgate
4462 rules to provide for a uniform and efficient provider
45-credentialing process. The superintendent shall approve no
46-more than two forms of application to be used for the
47-credentialing of dentists and dental hygienists.
48-B. A health insurance carrier shall not require a
49-dentist or dental hygienist to submit information not
50-required by a credentialing application established pursuant
51-to Subsection A of this section. HGEIC/HB 402
52-Page 2
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90+credentialing process. The superintendent shall approve no
91+more than two forms of application to be used for the
92+credentialing of providers.
93+B. A health insurance carrier shall not require a
94+provider to submit information not required by a credentialing
95+application established pursuant to Subsection A of this
96+section.
7897 C. The provisions of this section apply equally to
7998 initial credentialing applications and applications for
8099 recredentialing.
81100 D. The rules that the superintendent adopts and
82101 promulgates shall require primary credential verification no
83102 more frequently than every three years and allow provisional
84103 credentialing for a period of one year.
85104 E. Nothing in this section shall be construed to
86105 require a health insurance carrier to credential or
87-provisionally credential a dentist or dental hygienist.
106+provisionally credential a provider.
88107 F. The rules that the superintendent adopts and
89-promulgates shall establish that a health insurance carrier
90-or a health insurance carrier's agent shall:
91-(1) assess and verify the qualifications of
92-a dentist or dental hygienist who is applying to become a
93-participating provider within thirty calendar days of receipt
94-of a complete credentialing application and issue a decision
95-in writing to the applicant approving or denying the
96-credentialing application;
97-(2) be permitted to extend the credentialing
98-period to assess and issue a determination by an additional
99-fifteen calendar days if, upon review of a complete
100-application, it is determined that the circumstance
101-presented, including an admission of sanctions by the state
102-licensing board, an investigation or a felony conviction, a HGEIC/HB 402
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108+promulgates shall establish that a health insurance carrier or
109+a health insurance carrier's agent shall:
110+(1) assess and verify the qualifications of a
111+provider applying to become a participating provider within
112+thirty calendar days of receipt of a complete credentialing
113+application and issue a decision in writing to the applicant
114+approving or denying the credentialing application;
115+.229924.1
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129-revocation of clinical privileges or a denial of insurance
130-coverage, requires additional consideration;
131-(3) within ten working days after receipt of
132-a credentialing application, send a written notification via
133-United States certified mail to the applicant requesting any
143+(2) be permitted to extend the credentialing
144+period to assess and issue a determination by an additional
145+fifteen calendar days if, upon review of a complete
146+application, it is determined that the circumstance presented,
147+including an admission of sanctions by the state licensing
148+board, an investigation or a felony conviction, a revocation of
149+clinical privileges or a denial of insurance coverage, requires
150+additional consideration;
151+(3) within ten working days after receipt of a
152+credentialing application, send a written notification, via
153+United States certified mail, to the applicant requesting any
134154 information or supporting documentation that the health
135-insurance carrier requires to approve or deny the
136-credentialing application. The notice to the applicant shall
137-include a complete and detailed description of all of the
138-information or supporting documentation required and the
139-name, address and telephone number of a person who serves as
140-the applicant's point of contact for completing the
141-credentialing application process. Any information required
142-pursuant to this section shall be reasonably related to the
143-information in the application; and
155+insurance carrier requires to approve or deny the credentialing
156+application. The notice to the applicant shall include a
157+complete and detailed description of all of the information or
158+supporting documentation required and the name, address and
159+telephone number of a person who serves as the applicant's
160+point of contact for completing the credentialing application
161+process. Any information required pursuant to this section
162+shall be reasonably related to the information in the
163+application; and
144164 (4) no later than thirty calendar days as
145-described in Paragraph (1) of this subsection or an
146-additional fifteen days as described in Paragraph (2) of this
147-subsection, load into the health insurance carrier's provider
148-payment system all dentist or dental hygienist information,
149-including all information needed to correctly reimburse a
150-newly approved dentist or dental hygienist according to the
151-dentist's or dental hygienist's contract. The health
152-insurance carrier or health insurance carrier's agent shall
153-add the approved dentist's or dental hygienist's data to the HGEIC/HB 402
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165+described in Paragraph (1) of this subsection or an additional
166+fifteen days as described in Paragraph (2) of this subsection,
167+load into the health insurance carrier's provider payment
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180-provider directory upon loading the dentist's or dental
181-hygienist's information into the health insurance carrier's
196+system all provider information, including all information
197+needed to correctly reimburse a newly approved provider
198+according to the provider's contract. The health insurance
199+carrier or health insurance carrier's agent shall add the
200+approved provider's data to the provider directory upon loading
201+the provider's information into the health insurance carrier's
182202 provider payment system.
183203 G. A health insurance carrier shall reimburse a
184-dentist or dental hygienist for covered health care services
185-for any claims from the dentist or dental hygienist that the
186-health insurance carrier receives with a date of service more
187-than thirty calendar days after the date on which the health
188-insurance carrier received a complete credentialing
189-application for that dentist or dental hygienist if:
190-(1) the dentist or dental hygienist:
204+provider for covered health care services for any claims from
205+the provider that the health insurance carrier receives with a
206+date of service more than thirty calendar days after the date
207+on which the health insurance carrier received a complete
208+credentialing application for that provider if:
209+(1) the provider:
191210 (a) has submitted a complete
192-credentialing application and any supporting documentation
193-that the health insurance carrier has requested in writing
194-within the time frame established in Paragraph (3) of
195-Subsection F of this section;
211+credentialing application and any supporting documentation that
212+the health insurance carrier has requested in writing within
213+the time frame established in Paragraph (3) of Subsection F of
214+this section;
196215 (b) has no past or current license
197-sanctions or limitations, as reported by the New Mexico board
198-of dental health care or another pertinent licensing and
199-regulatory agency or a similar out-of-state licensing and
200-regulatory entity for a dentist or dental hygienist who is
201-licensed in another state; and
202-(c) has professional liability
203-insurance or is covered under the Medical Malpractice Act;
204-and HGEIC/HB 402
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216+sanctions or limitations, as reported by the New Mexico medical
217+board or another pertinent licensing and regulatory agency, or
218+by a similar out-of-state licensing and regulatory entity for a
219+provider licensed in another state; and
220+(c) has professional liability insurance
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249+or is covered under the Medical Malpractice Act; and
231250 (2) the health insurance carrier:
232251 (a) has approved, or has failed to
233252 approve or deny, the applicant's complete credentialing
234253 application within the time frame established pursuant to
235254 Paragraph (1) or (2) of Subsection F of this section; or
236255 (b) fails to load the approved
237256 applicant's information into the health insurance carrier's
238257 provider payment system in accordance with Paragraph (4) of
239258 Subsection F of this section.
240-H. A dentist or dental hygienist who, at the time
241-services were rendered, was not employed by a practice or
242-group that has contracted with the health insurance carrier
243-to provide services at specified rates of reimbursement shall
244-be paid by the health insurance carrier in accordance with
245-the health insurance carrier's standard reimbursement rate.
246-I. A dentist or dental hygienist who, at the time
247-services were rendered, was employed by a practice or group
248-that has contracted with the health insurance carrier to
249-provide services at specified rates of reimbursement shall be
250-paid by the health insurance carrier in accordance with the
251-terms of that contract.
259+H. A provider who, at the time services were
260+rendered, was not employed by a practice or group that has
261+contracted with the health insurance carrier to provide
262+services at specified rates of reimbursement shall be paid by
263+the health insurance carrier in accordance with the health
264+insurance carrier's standard reimbursement rate.
265+I. A provider who, at the time services were
266+rendered, was employed by a practice or group that has
267+contracted with the health insurance carrier to provide
268+services at specified rates of reimbursement shall be paid by
269+the health insurance carrier in accordance with the terms of
270+that contract.
252271 J. The superintendent shall adopt and promulgate
253272 rules to provide for the resolution of disputes relating to
254273 reimbursement and credentialing arising in cases where
255-credentialing is delayed beyond thirty days after HGEIC/HB 402
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282-application.
302+credentialing is delayed beyond thirty days after application.
283303 K. A health insurance carrier shall reimburse a
284-dentist or dental hygienist pursuant to Subsections G, H and
285-I of this section until the earlier of the following occurs:
286-(1) the health insurance carrier's approval
287-or denial of the dentist's or dental hygienist's complete
288-credentialing application; or
304+provider pursuant to Subsections G, H and I of this section
305+until the earlier of the following occurs:
306+(1) the health insurance carrier's approval or
307+denial of the provider's complete credentialing application; or
289308 (2) the passage of three years from the date
290-the health insurance carrier received the dentist's or dental
291-hygienist's complete credentialing application.
309+the health insurance carrier received the provider's complete
310+credentialing application.
292311 L. As used in this section:
293312 (1) "credentialing" means the process of
294-obtaining and verifying information about a dentist or dental
295-hygienist and evaluating that dentist or dental hygienist
296-when that dentist or dental hygienist seeks to become a
297-participating provider;
298-(2) "dental hygienist" means an individual
299-who has graduated and received a degree from a dental hygiene
300-educational program that is accredited by the commission on
301-dental accreditation, provides a minimum of two academic
302-years of dental hygiene curriculum and is an institution of
303-higher education; and "dental hygienist" means, except as the
304-context otherwise requires, an individual who holds a license
305-to practice dental hygiene in New Mexico; and
306-(3) "dentist" means a person who has HGEIC/HB 402
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333-graduated and received a degree from a school of dentistry
334-that is accredited by the commission on dental accreditation
335-and holds a license to practice dentistry in New Mexico."
313+obtaining and verifying information about a provider and
314+evaluating that provider when that provider seeks to become a
315+participating provider; and
316+(2) "provider" means a person who has
317+graduated and received a degree from a school of dentistry that
318+is accredited by the commission on dental accreditation and
319+holds a license to practice dentistry in New Mexico."
320+- 6 -
321+.229924.1