New Mexico Administrative Code
Title 13 - INSURANCE
Chapter 10 - HEALTH INSURANCE
Part 28 - PROVIDER PAYMENT AND PROVIDER CREDENTIALING REQUIREMENTS
Section 13.10.28.9 - PAYMENT OF CLAIMS, OVERDUE CLAIMS AND CALCULATION OF INTEREST
Universal Citation: 13 NM Admin Code 13.10.28.9
Current through Register Vol. 35, No. 18, September 24, 2024
A. Payment of claims - timeliness.
(1) Claim
payment. Health carriers shall promptly pay providers upon receipt of clean
claims for uncontested covered health care services that the provider has
supplied.
(2) Timeliness. The
health carrier shall reimburse the eligible provider within 30 days of the date
of receipt if the clean claim has been submitted electronically or within 45
days of the date of receipt if the clean claim has been submitted
manually.
(3) Prompt payment. For
purposes of prompt payment, a claim shall be deemed to have been "paid" upon
one of the following:
(a) a check is mailed
by the health carrier or its intermediary to the provider; or
(b) an electronic transfer of funds is made
by the health carrier or its intermediary to the provider.
(4) Reimbursement rate. The health carrier
shall make payment to the provider based on the standard reimbursement rate as
specified within the contractual agreement, or as otherwise agreed upon between
the health carrier and the provider.
(5) Multi-claim payments. A single payment
made to a provider can serve as payment for multiple claims, but must clearly
identify each claim and the amount of the claim that has been satisfied by the
payment. If non-claim payments to a provider are included in a multi-claim
payment, the nature of those payments must also be clearly
identified.
B. Interest on unpaid clean claims. A health carrier shall pay interest as set forth in Subsection D of 13.10.28.9 NMAC on the amount of any clean claim that has not been paid within the time specified in Subsection A of 13.10.28.9 NMAC.
C. Pending claims.
(1) Questionable liability and
special treatment claims.
(a) If, upon receipt
of a claim, a health carrier is unable to determine liability for, or otherwise
refuses to pay a claim or a portion of a claim of an eligible provider within
the time specified in Subsection A of 13.10.28.9 NMAC, the health carrier shall
make a good faith effort to notify the eligible provider electronically, in
writing, or by another method, as agreed between the health carrier and
provider, within 30 days of the date of receipt of the claim if submitted
electronically and within 45 days of the date of receipt of the claim if
submitted manually.
(b) If, upon
receipt of a claim, a health carrier determines that a claim or a portion of a
claim requires special treatment due to particular or unusual circumstances
that will delay payment beyond the time specified in Subsection A of 13.10.28.9
NMAC, the health carrier shall make a good faith effort to notify the eligible
provider electronically, in writing, or by another method, as agreed between
the health carrier and provider, within 30 days of the date of receipt of the
claim if submitted electronically and within 45 days of the date of receipt of
the claim if submitted manually.
(2) Notification of pending claims. The
notification required by Subsection C of 13.10.28.9 NMAC, shall:
(a) specify the reason(s) why the health
carrier is refusing to pay the claim, has determined it is not liable for the
claim, or shall specify what information is required to determine liability for
the claim;
(b) clearly indicate if
only certain charges associated with a claim are contested; and
(c) shall be repeated by the health carrier
at least monthly until the matter is resolved.
(3) Uncontested portion of pending claims.
The timely payment requirement described in Section A of 13.10.28.9 NMAC
applies to any uncontested portion of a contested claim.
(4) Liability resolved. The date on which
liability or special treatment issues are resolved for a pending claim is the
date that the claim becomes a clean claim and shall initiate the timely payment
requirement described in Subsection A of 13.10.28.9 NMAC.
D. Overdue payments, calculation of interest.
(1) When payment is not made
by the health carrier to the provider within the time specified in Subsection A
of 13.10.28.9 NMAC and there is no question of liability or special treatment
as described in Subsection C of 13.10.28.9 NMAC or questions of liability or
special treatment have been resolved, interest shall be calculated and paid to
the provider, on the unpaid portion of the claim as follows:
(a) For any full or partial month, beginning
on the 31st day after the claim has been submitted electronically and on the
46th day for claims submitted manually, the health carrier shall calculate and
pay interest in the amount of one and one-half percent for each full or partial
month. For purposes of this section, any 30-day period is the equivalent of one
month, excepting that a calendar year shall only be equal to 12 months;
and
(b) Interest shall be
calculated beginning the day after the required payment date and ending on the
date the claim is paid. The health carrier shall not be required to pay any
interest calculated to be less than two dollars ($2.00). The interest shall be
paid within 30 days of the payment of the claim. Interest can be paid on the
same check or electronic transfer as the claim payment or on a separate check
or electronic transfer. If the health carrier combines interest payments for
more than one late clean claim, the check or electronic transfer shall include
information identifying each claim covered by the check or electronic transfer
and the specific amount of interest being paid for each claim.
(2) When a claim that involves a
question of liability or special treatment is ultimately resolved in favor of
the provider and is not paid within 30 or 45 days of becoming an electronic or
manual clean claim, respectively, the health carrier shall pay all of the
interest due on the unpaid claim, to be calculated as described in Paragraph
(1) of Subsection D of 13.10.28.9 NMAC.
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.
