New Mexico Administrative Code › Title 7 - HEALTH › Chapter 5 - VACCINATIONS AND IMMUNIZATIONS › Part 4 - VACCINE PURCHASING FUND › Section 7.5.4.13 - INITIAL ADMINISTRATIVE REVIEW OF INVOICE BY THE DEPARTMENT

Current through Register Vol. 35, No. 13, July 16, 2024
A.Each health
				insurer or group health plan shall have the right to request an initial
				administrative review of their invoice by the department in the event of a
				dispute over the invoice amount only. Any other grievances shall be initiated
				with the office of the superintendent pursuant to their rules. Criteria for the
				initial administrative review of the invoice shall be available from the
				department of health immunization program. Any informal hearing or
				administrative review of the invoice pursuant to the office of the
				superintendent's rules can only be commenced after the department's initial
				administrative review of the invoice is completed and the health insurer or
				group health plan receives notification by mail that the administrative review
				request has been completed by the department.
B. The health insurer or group health plan
				may submit a letter requesting an initial administrative review of the invoice
				and any supporting documents to the immunization program manager or designee
				within 10 working days of receipt of the department's invoice. Such requests
				shall be submitted to the immunization program manager at P.O. Box 26110, Santa
				Fe, NM 87502-6110, and via email at vpa.fund@state. nm.us. The health insurer
				or group health plan shall send a copy of the request to the office of the
				superintendent of insurance.
C.
				Within 10 working days of receipt of the request for an initial administrative
				review of the invoice, the department of health's immunization program manager
				or designee shall review the request for an initial administrative review of
				the invoice and any supporting documents. After the administrative review is
				complete the department's immunization program manager or designee shall notify
				the health insurer or group health plan by mail if the invoice amount will
				remain unchanged or modified.
D. If
				a modified invoice is issued by the department then payment is due within five
				days of receipt of the modified invoice or on the due date identified in the
				original invoice, whichever is later. Payment is due regardless of whether the
				health insurer or group health plan intends to further pursue an administrative
				review or informal hearing of the invoice with the office of the superintendent
				or an appeal to district court. Failure to remit payment will result in the
				department reporting the failure of a health insurer or group health plan to
				reimburse the department to the office of the attorney general for collection
				of the invoice amount, including a civil penalty of five hundred dollars ($500)
				for each day from the date the payment is due.
E. If the invoice remains unchanged then the
				invoice amount is due within five days of receipt of the department's decision
				or on the due date identified in the original invoice, whichever is later.
				Payment is due regardless of whether the health insurer or group health plan
				intends to further pursue an administrative review or informal hearing of the
				invoice with the office of the superintendent or an appeal to district court.
				Failure to remit payment will result in the department reporting the failure of
				a health insurer or group health plan to reimburse the department to the office
				of the attorney general for collection of the invoice amount, including a civil
				penalty of five hundred dollars ($500) for each day from the date the payment
				is due.
F.If the health insurer or
				group health plan continues to dispute the invoice amount, then it may request
				an informal hearing or administrative review with the office of the
				superintendent pursuant to the office of the superintendent's rules as
				authorized by the Vaccine Purchasing Act. The health insurer or group health
				plan shall notify the immunization program manager if they are pursuing an
				informal hearing or administrative review of the invoice with the office of the
				superintendent via email at vpa.fund@state.nm.us .