New Mexico Administrative Code
Title 13 - INSURANCE
Chapter 10 - HEALTH INSURANCE
Part 28 - PROVIDER PAYMENT AND PROVIDER CREDENTIALING REQUIREMENTS
Section 13.10.28.13 - CREDENTIALING AND PAYMENT DISPUTE RESOLUTION
Universal Citation: 13 NM Admin Code 13.10.28.13
Current through Register Vol. 35, No. 18, September 24, 2024
A. Internal review process.
(1) Each health carrier shall establish an
internal process for resolving disputes regarding payment of claims between the
health carrier and providers arising when a credentialing decision is delayed
beyond the timeline found in Subsection C of 13.10.28.11 NMAC, the prompt
payment deadline described in Paragraph (2) of Subsection A of 13.10.28.9 NMAC
has passed, and payment has not been made.
(2) The internal process shall include
required notification regarding pending claims and calculation and payment of
interest on overdue claims, as described in Subsections C and D of 13.10.28.9
NMAC.
(3) The internal process
shall provide for resolution of disputes regarding reimbursement rates as
described in 13.10.28.12 NMAC.
(4)
At a minimum, the internal review process shall provide for the following:
(a) To initiate a payment dispute, the
provider shall contact the health carrier in writing to determine the status of
a claim, to ensure that sufficient documentation supporting the claim has been
provided, and to determine whether the claim is considered by the health
carrier to be a clean claim.
(b)
The health carrier shall respond in writing to a provider's inquiry regarding
the status of an unpaid claim within 15 days of receiving the
inquiry.
(c) The health carrier's
response shall explain its failure or refusal to pay, and the expected date of
payment if payment is pending.
(5) The internal review process may provide
specific procedures for resolving payment disputes, including by not limited
to, the use of medication.
B. Complaint filed with Superintendent.
(1) If the health
carrier fails to respond or the provider believes that payment is being denied,
delayed, or calculated in error and the matter has not been successfully
resolved at the internal level within 45 days, then the provider may file a
complaint, either individually or in batches, with the superintendent using the
form found on the OSI website.
(2)
Complaints filed with the superintendent shall contain the following
information:
(a) the provider's name,
identification number, address, daytime telephone number and the claim
number;
(b) the date that the
provider's request for credentialing was complete;
(c) the name and address of the health
carrier;
(d) the name of the
patient and employer (if known);
(e) the date(s) of service and the date(s)
the claims were submitted to the health carrier;
(f) relevant correspondence between the
provider and the health carrier, including requests for additional information
from the health carrier;
(g)
additional information which the provider believes would be of assistance in
the superintendent's review; and
(h) only those excerpts from provider
contracts that are minimally necessary to resolve the dispute shall be
submitted to the superintendent, who shall maintain the confidentiality of such
excerpts to the fullest extent allowed by applicable law.
(3) The complaining provider shall furnish
the health carrier with a complete copy of the complaint and submitted
documentation concurrently with the provider's submission to the
superintendent.
(4) The health
carrier shall be afforded 10 business days after the provider's submission to
resolve the matter or to submit additional information that the health carrier
believes would be of assistance to the superintendent's review.
(5) The superintendent will review the
matter, based on documents and other materials that are submitted by the
provider and health carrier for this purpose.
(6) The superintendent may issue an order
resolving the dispute, with or without a hearing.
(7) If the superintendent determines, at his
sole discretion, that a hearing is necessary, then the provider and the health
carrier may appear and may elect to be represented by counsel at the
hearing.
(8) The superintendent may
designate one or more persons to act as hearing officer. The hearing officer
shall prepare a recommendation for the superintendent's review.
(9) The superintendent's decision will be
issued within 30 days of receiving a payment complaint if no hearing is
required or within 30 days of the hearing, if a hearing is held.
(10) The superintendent may order a health
carrier to reimburse a provider at the standard reimbursement rate for covered
services provided to the health carrier's enrollees, subject to out-of-network
costs, deductibles, co-payments, co-insurance or other cost-sharing provisions
due from the enrollee.
(11) In
addition to any applicable suspension, revocation or refusal to continue any
certificate of authority or license under the insurance code, the
superintendent may find that violators of the regulations set forth in this
section are subject to the standard penalties for material violations of the
insurance code, in accordance with sections
59A-1-18 and
59A-46-25
NMSA 1978.
(12) The provisions of
this subsection do not prevent the superintendent from investigating a
complaint when the provider has failed to contact the health
carrier.
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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