2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22 - Health Insurance Contracts › Section 59A-22-54 - Provider credentialing; requirements; deadline.

A. The superintendent shall adopt and promulgate rules to provide for a uniform and efficient provider credentialing process. The superintendent shall approve no more than two forms of application to be used for the credentialing of providers.
B. An insurer shall not require a provider to submit information not required by a credentialing application established pursuant to Subsection A of this section.
C. The provisions of this section apply equally to initial credentialing applications and applications for recredentialing.
D. The rules that the superintendent adopts and promulgates shall require primary credential verification no more frequently than every three years and allow provisional credentialing for a period of one year.
E. Nothing in this section shall be construed to require an insurer to credential or provisionally credential a provider.
F. The rules that the superintendent adopts and promulgates shall establish that an insurer or an insurer's agent shall:
(1) assess and verify the qualifications of a provider applying to become a participating provider within thirty calendar days of receipt of a complete credentialing application and issue a decision in writing to the applicant approving or denying the credentialing application;
(2) be permitted to extend the credentialing period to assess and issue a determination by an additional fifteen calendar days if, upon review of a complete application, it is determined that the circumstance presented, including an admission of sanctions by the state licensing board, investigation or felony conviction, revocation of clinical privileges or denial of insurance coverage, requires additional consideration;
(3) within ten working days after receipt of a credentialing application, send a written notification, via United States certified mail, to the applicant requesting any information or supporting documentation that the insurer requires to approve or deny the credentialing application. The notice to the applicant shall include a complete and detailed description of all of the information or supporting documentation required and the name, address and telephone number of a person who serves as the applicant's point of contact for completing the credentialing application process. Any information required pursuant to this section shall be reasonably related to the information in the application; and
(4) no later than thirty calendar days as described in Paragraph (1) of this subsection or an additional fifteen days as described in Paragraph (2) of this subsection, load into the insurer's provider payment system all provider information, including all information needed to correctly reimburse a newly approved provider according to the provider's contract. The insurer or insurer's agent shall add the approved provider's data to the provider directory upon loading the provider's information into the insurer's provider payment system.
G. An insurer shall reimburse a provider for covered health care services for any claims from the provider that the insurer receives with a date of service more than thirty calendar days after the date on which the insurer received a complete credentialing application for that provider if:
(1) the provider:
(a) has submitted a complete credentialing application and any supporting documentation that the insurer has requested in writing within the time frame established in Paragraph (3) of Subsection F of this section;
(b) has no past or current license sanctions or limitations, as reported by the New Mexico medical board or another pertinent licensing and regulatory agency, or by a similar out-of-state licensing and regulatory entity for a provider licensed in another state; and
(c) has professional liability insurance or is covered under the Medical Malpractice Act [Chapter 41, Article 5 NMSA 1978]; and
(2) the insurer:
(a) has approved, or has failed to approve or deny, the applicant's complete credentialing application within the time frame established pursuant to Paragraph (1) or (2) of Subsection F of this section; or
(b) fails to load the approved applicant's information into the insurer's provider payment system in accordance with Paragraph (4) of Subsection F of this section.
H. A provider who, at the time services were rendered, was not employed by a practice or group that has contracted with the insurer to provide services at specified rates of reimbursement shall be paid by the insurer in accordance with the insurer's standard reimbursement rate.
I. A provider who, at the time services were rendered, was employed by a practice or group that has contracted with the insurer to provide services at specified rates of reimbursement shall be paid by the insurer in accordance with the terms of that contract.
J. The superintendent shall adopt and promulgate rules to provide for the resolution of disputes relating to reimbursement and credentialing arising in cases where credentialing is delayed beyond thirty days after application.
K. An insurer shall reimburse a provider pursuant to Subsections G, H and I of this section until the earlier of the following occurs:
(1) the insurer's approval or denial of the provider's complete credentialing application; or
(2) the passage of three years from the date the insurer received the provider's complete credentialing application.
L. As used in this section:
(1) "credentialing" means the process of obtaining and verifying information about a provider and evaluating that provider when that provider seeks to become a participating provider; and
(2) "provider" means a physician or other individual licensed or otherwise authorized to furnish health care services in a state.
History:
Laws 2015, ch. 111, § 1; 2016, ch. 20, § 2; 2023, ch. 175, § 1.
ANNOTATIONS
The 2023 amendment,
effective June 16, 2023, required the superintendent of insurance to promulgate rules establishing a time frame for insurers to load information on approved providers into their provider payment systems, and required insurers to reimburse approved providers if the insurers fail to load that information within the established period; in Subsection F, Paragraph F(1), after "provider within", deleted "forty-five" and added "thirty"; added a new Paragraph F(2) and redesignated former Paragraph F(2) as Paragraph F(3); and added Paragraph F(4); in Subsection G, in the introductory clause, after "more than", deleted "forty-five" and added "thirty"; in Subparagraph G(1)(a), after "Paragraph", deleted "(2)" and added "(3)"; deleted former Paragraph G(2) and added a new Paragraph G(2); redesignated former Paragraphs G(3) and G(4) as Subparagraphs G(1)(b) and G(1)(c), respectively; and in Subsection J, after "delayed beyond", deleted "forty-five" and added "thirty".
The 2016 amendment,
effective May 18, 2016, amended credentialing requirements for health care providers and amended reimbursement procedures for certain providers; in Subsection A, in the second sentence, after "The", deleted "rules shall establish a single credentialing application form" and added "superintendent shall approve no more than two forms of application to be used"; in Subsection B, after "not required by", deleted "the uniform" and added "a"; in Subsection C, after "equally to", added "initial"; in Subsection D, after "promulgates", deleted "pursuant to Subsection A of this section", and after "every three years", added "and allow provisional credentialing for a period of one year."; added a new Subsection E and redesignated former Subsections E and F as Subsections F and G, respectively; in Subsection F, in the introductory sentence, after "promulgates", deleted "pursuant to Subsection A of this section"; in Subsection G, deleted "Except as provided pursuant to Subsection G of this section", in the introductory sentence, after "health care services", deleted "in accordance with the carrier's standard reimbursement rate", in Paragraph (1), after "Subsection", deleted "E" and added "F", in Paragraph (2), after "the insurer has", added "approved, or has", and after "Subsection", deleted "E" and added "F"; added new Subsection H and redesignated former Subsections G, H, I and J as Subsections I, J, K and L, respectively; in Subsection I, deleted "In cases where", after "A provider", deleted "is joining an existing" and added "who, at the time services were rendered, was employed by a", and after "has contracted", deleted "reimbursement rates with an insurer, the insurer shall pay the provider" and added "with the insurer to provide services at specified rates of reimbursement shall be paid by the insurer"; in Subsection K, in the introductory sentence, after "pursuant to", deleted "the circumstances set forth in Subsection F" and added "Subsections G, H and I", and in Paragraph (2), after "date the", deleted "carrier" and added "insurer"; and in Subsection L, Paragraph (2), after "services in", deleted "the" and added "a".
Applicability.
— Laws 2016, ch. 20, § 7B provided that the provisions of Laws 2016, ch. 20, §§ 2 through 5 apply to applications for provider credentialing made on or after January 1, 2017.