New Mexico Administrative Code
Title 13 - INSURANCE
Chapter 10 - HEALTH INSURANCE
Part 28 - PROVIDER PAYMENT AND PROVIDER CREDENTIALING REQUIREMENTS
Section 13.10.28.11 - TIMELY CREDENTIALING DECISIONS
Universal Citation: 13 NM Admin Code 13.10.28.11
Current through Register Vol. 35, No. 18, September 24, 2024
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.
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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