New Mexico Administrative Code
Title 13 - INSURANCE
Chapter 10 - HEALTH INSURANCE
Part 28 - PROVIDER PAYMENT AND PROVIDER CREDENTIALING REQUIREMENTS
Section 13.10.28.10 - GENERAL PROVIDER CREDENTIALING
Universal Citation: 13 NM Admin Code 13.10.28.10
Current through Register Vol. 35, No. 18, September 24, 2024
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.
Disclaimer: These regulations may not be the most recent version. New Mexico may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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