New Mexico Administrative Code
Title 13 - INSURANCE
Chapter 10 - HEALTH INSURANCE
Part 30 - PHARMACY BENEFITS MANAGERS
Section 13.10.30.10 - PHARMACY GRIEVANCES

Universal Citation: 13 NM Admin Code 13.10.30.10

Current through Register Vol. 35, No. 18, September 24, 2024

A. Health plans subject to 13.10.16 NMAC: a pharmacy grievance relating to a PBM who is performing services for a health plan or carrier subject to rule 13.10.16 NMAC shall be governed by that rule.

B. Health plans not subject to 13.10.16 NMAC: A pharmacy with a grievance relating to a PBM who is performing services for health plan or carrier that is not subject to rule 13.10.16 NMAC may file a grievance against the PBM with the superintendent.

(1) A grievance by a pharmacy against a PBM shall be in writing on a form provided by the superintendent.

(2) A pharmacy shall submit a grievance within six months from the date the pharmacy new or should have known of alleged PBM misconduct.

(3) A grievance may allege multiple violations against a single PBM.

(4) A pharmacy shall provide supporting documentation.

(5) The superintendent shall transmit any grievance, including supporting documentation to the e-mail contact designated by the PBM to receive grievance.

(6) The superintendent will specify the documentation necessary to address the grievance.

(7) A PBM shall have 14 business days from receipt of the grievance to respond in writing.

(8) The superintendent may request additional documentation. The PBM shall provide any additional documentation in writing within 14 business days from the date of the superintendent's request.

(9) The superintendent may grant a PBM's request for an extension of time.

(10) The superintendent will send a copy of all submissions received in connection to a grievance to the opposing party.

C. Enforcement: If the superintendent finds probable cause that a PBM violated a law enforceable by the superintendent, the superintendent may issue a notice to show cause, why the superintendent should not take specified enforcement action against the PBM and its principal.

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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