New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 21 - HEALTH CARE SERVICES AND PROVIDER CREDENTIALING REQUIRED FOR HMOs › Section 13.10.21.9 - UNIFORM PROVIDER CREDENTIALING FOR HEALTH MAINTENANCE ORGANIZATIONS (HMOS)

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Delegation of credential verification activities:
Whenever an HMO
				delegates credential verification activities to a contracting entity, whether a
				credentialing intermediary or subcontractor, the HMO shall review and approve
				the contracting entity's credential verification program before contracting and
				shall require that the entity comply with all applicable requirements of this
				regulation. The HMO shall monitor the contracting entity's credential
				certification activities. The HMO shall implement oversight mechanisms,
				including (a) reviewing the contracting entity's credential verification plans,
				policies, procedures, forms, and adherence to verification procedures, (b)
				requiring the contract entity to submit an updated list of health professionals
				no less frequently than quarterly, and (c) conducting an evaluation of the
				contracting entity's credential verification program at least every two years.
				The HMO's monitoring activities should at least meet the verification
				procedures and standards as defined by the national committee for quality
				assurance (NCQA).
B.
Credential verification program:
In order to assure accessibility and
				availability of services, each HMO shall establish a program in accordance with
				this regulation that verifies that its network providers are credentialed
				before the HMO lists those providers in the HMO's provider directory,
				handbooks, or other marketing or member materials. The credential verification
				program established by each HMO shall provide for an identifiable person or
				persons to be responsible for all credential verification activities, which
				person or persons shall be capable of carrying out that
				responsibility.
C.
Written
				credential verification plan:
Each HMO shall develop and adopt a written
				credentialing plan that contains policies and procedures to support the
				credentialing verification program. The plan shall include the purpose, goals
				and objectives of the credential verification program; and the roles of those
				persons responsible for the credential verification program.
D.
Use of uniform credentialing forms
				required:
Beginning September 1, 2009, an HMO shall not use any health
				professional credentialing application form other than uniform HSC or CAQH
				credentialing or re-credentialing forms. Should the superintendent determine
				that these forms no longer represent industry standards, the superintendent
				will issue a bulletin advising of alternative forms to be used to satisfy this
				requirement. The uniform credentialing or re-credentialing forms may be used in
				electronic or paper format, as determined by the HMO. An HMO shall not require
				an applicant to submit information not required by the uniform credentialing or
				re-credentialing forms. An exception is made for health professionals who:
(a) are subject to credentialing under the
				HMO's internal policy;
(b) practice
				outside of New Mexico; and (c) prefer to use the credentialing forms required
				by their respective states. In such circumstances, the HMO and its delegated
				entity, if any, may accept those forms.