New Mexico Administrative Code
Title 13 - INSURANCE
Chapter 10 - HEALTH INSURANCE
Part 28 - PROVIDER PAYMENT AND PROVIDER CREDENTIALING REQUIREMENTS
Section 13.10.28.8 - CLAIM SUBMISSION AND CODING CHANGES
Universal Citation: 13 NM Admin Code 13.10.28.8
Current through Register Vol. 35, No. 18, September 24, 2024
A. General.
(1) Health carriers shall comply with both
the provisions of this section and with the provisions of 13.10.12 NMAC, which
provides for standardization of health claim forms.
(2) Claims information, including claim
status information shall be subject to state and federal patient privacy
protection laws.
(3) A health
carrier that has entered into a contract with one or more intermediaries to
conduct provider credentialing or provide payments to providers shall require
the intermediary to indicate the name of the intermediary and the name of the
health carrier for which it is conducting the work when contacting a provider
on behalf of the health carrier.
B. Electronic submission.
(1) Health carriers shall make available to
participating providers a process and procedure for submitting claims
electronically.
(2) Health
carriers shall make available to participating providers a process and
procedure for electronically making coding changes for claims after
submission.
(3) Claims that are
transmitted electronically are deemed to be received by the health carrier on
the date of receipt unless the provider receives immediate notice of a
transmission error.
(4) When a
claim is submitted electronically and the health carrier subsequently
determines that there is an error or omission with the submission that will
delay or prevent payment to the participating provider, the health carrier
shall make a good faith effort to notify the participating provider by fax,
electronic, or other written communication within 30 days following the date of
receipt.
(5) Any notification from
a health carrier to a provider that there is an error or omission in a claim
submission must contain a specific statement regarding all information sought
to rectify the error or omission. The carrier shall make a good faith effort to
convey all of the errors or omissions to the provider at one time. A pattern of
repetitive requests for the same information from a health carrier to a
provider is a violation of Article 16 of the Insurance Code, as defined at
§
59A-16-20.
C. Manual submission.
(1) Health carriers shall make standard forms
available to providers for submitting claims manually via US mail, fax, e-mail,
or hand delivery.
(2) Health
carriers shall make standard forms available to providers for manual coding
changes to be submitted via US mail, fax, e-mail, or hand delivery.
(3) Claims that are submitted via US mail are
deemed to be received by the health carrier on the date of receipt. Claims that
are transmitted via fax, E-mail or hand delivery are deemed to be received by
the health carrier on the date of receipt unless the provider receives
immediate notice of a transmission error.
(4) When a claim is submitted manually and
the health carrier subsequently determines that there is an error or omission
with the submission that will delay or prevent payment to the provider, the
health carrier shall make a good faith effort to notify the participating
provider in writing within 45 days following the date of receipt.
(5) Any notification from a health carrier to
a provider that there is an error or omission in a claim submission must
contain a specific statement regarding all information sought to rectify the
error or omission. The carrier shall make a good faith effort to convey all of
the errors or omissions to the provider at one time. A pattern of repetitive
requests for the same information from a health carrier to a provider is
violation of Article 16 of the Insurance Code, as defined at §
59A-16-20.
D. Access to Claims Status Information.
(1) Health carriers
shall provide an electronic means whereby participating providers can access
claim information within three business days of the date of receipt for
electronic claims and within 10 business days of the date of receipt for manual
claims.
(2) The information that is
available to the provider shall indicate the status of the request for payment,
including, but not limited to the following:
(a) date of receipt;
(b) identifying claim information, which may
include enrollee/covered persons identifiers, date(s) of service, and
appropriate coding, as required by the health carrier and agreed to by the
provider;
(c) whether the claim is
pending or if it has been accepted or rejected for payment;
(d) if the claim is pending, whether the
health carrier has requested additional information from the provider to
complete processing of the claim;
(e) if the claim has been accepted, the
payment amount that has been approved; and
(f) a clear explanation of the circumstances
if the claim has been found to involve particular or unusual circumstances that
require special treatment and that are likely to delay payment.
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.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
