New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 2 - PROVIDER NETWORK › Section 8.308.2.9 - GENERAL REQUIREMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
The HSD managed care organization (MCO) shall establish and
				  maintain a comprehensive network of providers and required specialists in
				  sufficient numbers to make all services included in the benefit package
				  available in accordance with access standards. The MCO shall require any
				  contracted provider to be enrolled through a fully executed provider
				  participation agreement (PPA) with HSD's medical assistance division (MAD). In
				  completing the PPA, the provider may choose to participate only in managed
				  care, only in fee-for-service, or both. Providers who have completed a PPA can
				  choose to pursue contracting with one or more MCOs but do not have to contract
				  with all MCOs. The MCO shall refer any provider who notifies the MCO of a
				  change in his or her location, licensure, certification, or status to the MAD
				  provider web portal to update his or her provider information. In addition, the
				  MCO shall provide an e-mail notification to MAD regarding changes in provider
				  servicing location; change in licensure or certification; and the date on which
				  the provider is no longer participating with the MCO, including the
				  reason.
A. Required MCO policies and
				procedures:
(1) Pursuant to section 1932(b)(7)
				of the Social Security Act, and consistent with
				42 CFR
				438.12, the MCO shall not discriminate
				against a provider that serves high-risk populations or specializes in
				conditions that require costly treatment.
(2) The MCO shall not discriminate with
				respect to participation, reimbursement, or indemnification of any provider
				acting within the scope of his or her provider's license or certification under
				applicable state statute or rule solely on the basis of the provider's license
				or certification.
(3) The MCO shall
				upon declining to include an individual or a group of providers in its network,
				give the affected provider written notice of the reason for the MCO
				decision.
(4) The MCO shall conduct
				screenings of all subcontractors and contract providers in accordance with the
				Employee Abuse Registry Act, 27-7A-3 NMSA 1978, the New Mexico Caregivers
				Criminal History Screening Act, 2-17-2 et seq., NMSA 1978 and 7.1.9 NMAC, the
				New Mexico Children's and Juvenile Facility Criminal Records Screening Act,
				32A-15-1 to 32A-15-4 NMSA 1978, Patient Protection and Affordable Care Act
				(PPACA), and ensure that all subcontracted and contracted providers are
				screened against the federal "list of excluded individuals or entities" (LEIE)
				and the federal "excluded parties list system" (EPLS) (now known as the system
				for award management (SAM)) and any other databases that may be required
				through federal or state regulation.
(5) The MCO shall require that any provider,
				including a provider making a referral or ordering a covered service, have a
				national provider identifier (NPI) unless the provider is an atypical provider
				as defined by the centers for medicare and medicaid services (CMS).
(6) The MCO shall require that each provider
				billing for or rendering services to a MCO member has a unique identifier in
				accordance with the provisions of Section 1173(b) of the Social Security
				Act.
(7) The MCO shall consider in
				establishing and maintaining the network of appropriate providers its:
(a) anticipated enrollment;
(b) numbers of contracted providers who are
				not accepting new patients; and
(c)
				geographic locations of contracted providers and members, considering distance,
				travel time, the means of transportation ordinarily used by members; and
				whether the location provides physical access for members with
				disabilities.
(8) The
				MCO shall ensure that a contracted provider offers hours of operation that are
				no less than the hours of operation offered to its commercial
				enrollees.
(9) The MCO shall
				establish mechanisms such as notices or training materials to ensure that a
				contracted provider comply with the timely access requirements, monitor such
				compliance regularly, and take corrective action if there is a failure to
				comply.
(10) The MCO shall provide
				to its members and contracted providers clear instructions on how to access
				covered services, including those that require prior approval and
				referral.
(11) The MCO shall ensure
				that all contracted providers meet all availability; time and distance
				standards set by HSD, and have a system to track and report this
				data.
(12) The MCO shall provide
				access to a non-contracted provider if the MCO is unable to provide covered
				benefits covered under its agreement with HSD in an adequate and timely manner
				to a member and continue to authorize the use of a non-contracted provider for
				as long as the MCO is unable to provide these services through its contracted
				providers. The MCO must ensure that the cost to its members utilizing a
				non-contracted provider is not greater than it would be if the service was
				provided within the MCO's network.