SB 232 — HEALTH INSURER PROVIDER INFO & REIMBURSEMENT

g e i k B.

An insurer shall not require a provider to h r i s submit information not required by a credentialing application h , t, e u g established pursuant to Subsection A of this section.

e b l e e h C.

The provisions of this section apply equally to n d d i = = o h initial credentialing applications and applications for l ] b ,d i a º e r i = r recredentialing.

t e w d m a n o D.

The rules that the superintendent adopts and dSB m232 :Page 6 promulgates shall require primary credential verification no more frequently than every three years and allow provisional credentialing for a period of one year.

b e d s º o t n = .223074.1AIC March 10, 2023 (5:59pm) s k m e - 7 - e a n e d r e l u [ A d promulgates shall require primary credential verification no more frequently than every three years and allow provisional credentialing for a period of one year.

(1) assess and verify the qualifications of a provider applying to become a participating provider within [forty-five ] 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;

[and(2) ] Sfl1ºSHPACº(2) be permitted to extend the credentialing period to assess and issue a determination by an h g additional fifteen calendar days,days ifif, upon review of a complete o t hr application, it is determined that the circumstance presented, g e i k including an admission of sanctions by the state licensing h r i s h board, investigation or felony conviction, revocation of , t, e u g clinical privileges or denial of insurance coverage, requires e b l e e h additional consideration;»SHPAC»Sfl1consideration; n d d i = = o h l ] b ,d Sfl1º (2) be permitted to extend the i a º e r i = r credentialing period to assess and issue a determination by an t e w d m a n o d m :

b(3) e d s º o t n = .223074.1AIC March 10, 2023 (5:59pm) s k m e - 8 - e a n e d r e l u [ A d 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;»Sfl1 Sfl1º SHPACº(2)»SHPAC SHPACº(3)»SHPAC»Sfl1 Sfl1º (3)»Sfl1 within ten working days after receipt of a credentialing application, send a written notification, via United States certified mail, to the applicant requesting any SB 232 Page 7 information or supporting documentation that the insurer requires to approve or deny the credentialing application.

h Any information required pursuant to this section shall be u » r t h reasonably related to the information in the application;

and g(4) e l i Sfl1ºSHPACº(3)»SHPAC SHPACº(4)»SHPAC»Sfl1 h r i s Sfl1º (4)»Sfl1 no later than thirty SHPACºdayscalendar after receipt h , e h t u g of a complete credentialing application»SHPAC SHPACºcalendar e b l e e , gh days as described in Paragraph (1) of this subsection or an n d d i = = o h l ] b ,d additional fifteen days as described in Paragraph (2) of this isubsection, aload ºinto rthe einsurer's rprovider =payment subsection»SHPACsystem ,all loadprovider intoinformation, theincluding insurer'sall providerinformation paymentneeded tto ecorrectly wreimburse da mnewly aapproved nprovider oaccording dto mthe :provider's contract.

b r e t º o t n = .223074.1AIC March 10, 2023 (5:59pm) s k m e - 9 - e a n e d r e l u [ A d system all provider information, including all information needed to correctly reimburse a newly approved provider according to the provider's contract.

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 [forty-five ] thirty calendar days after the date on which the insurer received a complete credentialing application for that provider [provided that ] if:

SB 232 Page 8 (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 SHPACº(3) (2)»SHPAC SHPACº(3)»SHPAC of h g Subsection F of this section;

o(b) thas hrno [(2)past theor insurercurrent haslicense approved,sanctions or haslimitations, failedas greported eby i k to approve or deny, the applicant'sNew completeMexico credentialingmedical hboard ror ianother spertinent applicationlicensing withinand theregulatory timeagency, frameor establishedby pursuanta tosimilar hout-of-state ,licensing t,and eregulatory uentity gfor Paragrapha (1)provider oflicensed Subsectionin Fanother ofstate; this section;

eand b(c) l e e h (3) the provider] n d d i = = o h (b) has noprofessional pastliability orinsurance current license l ] b ,d i a º e r i = r sanctions or limitations,is ascovered reportedunder by the NewMedical MexicoMalpractice medicalAct; t e w d m a n o board or another pertinent licensing and regulatory agency, or d m :

b e d s º o t n = .223074.1AIC March 10, 2023 (5:59pm) s k m e - 10 - e a n e d r e l u [ A d by a similar out-of-state licensing and regulatory entity for a provider licensed in another state;

and [(4) the provider ] (c) has professional liability insurance or is covered under the Medical Malpractice Act;

(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) SHPACºoror (2)»SHPAC(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 SHPACº(3)»SHPAC(4) SHPACº (4)»SHPAC of Subsection F of this section.

A provider who, at the time services were rendered, was not employed by a practice or group that has hSB g232 Page 9 contracted with the insurer to provide services at specified o t hr rates of reimbursement shall be paid by the insurer in g e i k accordance with the insurer's standard reimbursement rate.

h r i s h I.

A provider who, at the time services were , t, e u g rendered, was employed by a practice or group that has e b l e e h contracted with the insurer to provide services at specified n d d i = = o h rates of reimbursement shall be paid by the insurer in l ] b ,d i a º e r i = r accordance with the terms of that contract.

t e w d m a n o J.

The superintendent shall adopt and promulgate drules mto :provide for the resolution of disputes relating to reimbursement and credentialing arising in cases where credentialing is delayed beyond thirty days after application.

b e d s º o t n = .223074.1AIC March 10, 2023 (5:59pm) s k m e - 11 - e a n e d r e l u [ A d rules to provide for the resolution of disputes relating to reimbursement and credentialing arising in cases where credentialing is delayed beyond [forty-five ] thirty days after application.

(1) "credentialing" means the process of obtaining and verifying information about a provider and evaluating that provider when that provider seeks to become a SB 232 Page 10 participating provider;

and h g (2) "provider" means a physician or other o t hr individual licensed or otherwise authorized to furnish health g e i k care services in the state." h r i s SECTION 3.

Section 59A-46-54 NMSA 1978 (being Laws 2015, h , t, e u g Chapter 111, Section 4, as amended) is amended to read:

e b l e e h "59A-46-54.

PROVIDER CREDENTIALING--REQUIREMENTS-- n d d i = = o h DEADLINE.-- l ] b ,d i a º e r i = r A.

The superintendent shall adopt and promulgate t e w d m a n o rules to provide for a uniform and efficient provider dcredentialing mprocess. :

b e d s º o t n = .223074.1AIC March 10, 2023 (5:59pm) s k m e - 12 - e a n e d r e l u [ A d credentialing process.

SB 232 Page 11 E.

The rules that the superintendent adopts and h g promulgates shall establish that a carrier or a carrier's agent o t hr shall:

g e i k (1) assess and verify the qualifications of a h r i s provider applying to become a participating provider within h , t, e u g [forty-five ] thirty calendar days of receipt of a complete e b l e e h credentialing application and issue a decision in writing to n d d i = = o h the applicant approving or denying the credentialing l ] b ,d i a º e r i = r application;

[and(2) ]be tpermitted eto wextend dthe mcredentialing period to assess and issue a ndetermination oby Sfl1ºSHPACº(2)an beadditional permittedfifteen tocalendar extenddays if, upon review of a complete application, it is determined that the dcircumstance mpresented, :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;

b(3) e d s º o t n = .223074.1AIC March 10, 2023 (5:59pm) s k m e - 13 - e a n e d r e l u [ A d 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;»SHPAC»Sfl1 Sfl1º (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;»Sfl1 Sfl1º SHPACº(2)»SHPAC SHPACº(3)»SHPAC»Sfl1 Sfl1º (3)»Sfl1 within ten working days after receipt of a h u credentialing application, send a written notification, via » r t h United States certified mail, to the applicant requesting any g e l i information or supporting documentation that the carrier h r i s h , requires to approve or deny the credentialing application.

The e h t u g notice to the applicant shall include a complete and detailedSB e232 bPage l12 edetailed e , gh description of all of the information or supporting n d d i = = o h l ] b ,d documentation required and the name, address and telephone i a º r e r = number of a person who serves as the applicant's point of tcontact efor wcompleting dthe mcredentialing aapplication nprocess. o d m :

b r e t º o t n = .223074.1AIC March 10, 2023 (5:59pm) s k m e - 14 - e a n e d r e l u [ A d contact for completing the credentialing application process.

and Sfl1ºSHPACº(3)»SHPAC(4) SHPACº(4)»SHPAC»Sfl1 Sfl1º (4)»Sfl1 no later than thirty SHPACºdayscalendar after receipt of a complete credentialing application»SHPAC SHPACºcalendar days as described in Paragraph (1) of this subsection or an additional fifteen days as described in Paragraph (2) of this subsection»SHPACsubsection, , load into the carrier's provider payment system all provider information, including all information needed to correctly reimburse a newly approved provider according to the provider's contract.

A carrier shall reimburse a provider for covered health care services for any claims from the provider that the h g carrier receives with a date of service more than [forty-five ] o t hr thirty calendar days after the date on which the carrier g e i k received a complete credentialing application for that provider h r i s h [provided that ] if:

, t, e u g (1) the provider:

e b l e e h (a) has submitted a complete n d d i = = o h l ] b ,d credentialing application and any supporting documentation thatSB i232 aPage º13 ethat r i = r the carrier has requested in writing within the time frame t e w d m a n o established in Paragraph SHPACº(3) (2)»SHPACof SHPACº(3)»SHPACSubsection F of dthis msection; :

b(b) ehas dno spast ºor ocurrent tlicense nsanctions =or .223074.1AIClimitations, Marchas 10,reported 2023by (5:59pm)the sNew kMexico mmedical eboard -or 15another -pertinent elicensing aand nregulatory eagency, dor rby ea lsimilar uout-of-state [licensing Aand dregulatory Subsectionentity Ffor ofa thisprovider section;licensed in another state;

[(2)and the(c) carrier has approved,professional orliability hasinsurance failed to approve or deny,is thecovered applicant'sunder complete credentialing application within the timeMedical frameMalpractice establishedAct; pursuant to Paragraph (1) of Subsection F of this section;

(3) the provider] (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 [(4) the provider ] (c) has professional liability insurance or is covered under the Medical Malpractice Act;

(a) has approved, or has failed to approve or deny, the applicant's complete credentialing h g application within the time frame established pursuant to o t hr Paragraph (1) SHPACºoror (2)»SHPAC(2) of Subsection F of this g e i k section;

or h r i s (b) fails to load the approved h , t, e u g applicant's information into the carrier's provider payment e b l e e h system in accordance with Paragraph SHPACº(3)»SHPAC(4) n d d i = = o h SHPACº (4)»SHPAC of Subsection F of this section.

l ] b ,d i a º e r i = r H.

A provider who, at the time services were t e w d m a n o rendered, was not employed by a practice or group that has dcontracted mwith :the carrier to provide services at specified rates of reimbursement shall be paid by the carrier in accordance with the carrier's standard reimbursement rate.

bSB e232 dPage s14 ºI. o t n = .223074.1AIC March 10, 2023 (5:59pm) s k m e - 16 - e a n e d r e l u [ A d contracted with the carrier to provide services at specified rates of reimbursement shall be paid by the carrier in accordance with the carrier's standard reimbursement rate.

I.

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 [forty-five ] thirty days after application.

(1) the carrier's approval or denial of the h g provider's complete credentialing application;

or o t hr (2) the passage of three years from the date g e i k the carrier received the provider's complete credentialing h r i s application." h , t, e u g SECTION 4.

Section 59A-47-49 NMSA 1978 (being Laws 2015, e b l e e h Chapter 111, Section 6, as amended) is amended to read:

n d d i = = o h "59A-47-49.

PROVIDER CREDENTIALING--REQUIREMENTS-- l ] b ,d i a º e r i = r DEADLINE.-- t e w d m a n o A.

The superintendent shall adopt and promulgate drules mto :provide for a uniform and efficient provider SB 232 Page 15 credentialing process.

b e d s º o t n = .223074.1AIC March 10, 2023 (5:59pm) s k m e - 17 - e a n e d r e l u [ A d rules to provide for a uniform and efficient provider credentialing process.

Nothing in this section shall be construed to require a health care plan to credential or provisionally h g credential a provider.

o t hr F.

The rules that the superintendent adopts and g e i k promulgates shall establish that a health care plan or a health h r i s care plan's agent shall:

h , t, e u g (1) assess and verify the qualifications of a e b l e e h provider applying to become a participating provider within n d d i = = o h [forty-five ] thirty calendar days of receipt of a complete l ] b ,d i a º e r i = r credentialing application and issue a decision in writing to t e w d m a n o the applicant approving or denying the credentialing dapplication; m :

bSB e232 dPage s16 º(2) obe tpermitted nto =extend .223074.1AICthe Marchcredentialing 10,period 2023to (5:59pm)assess sand kissue ma edetermination -by 18an -additional efifteen calendar days if, upon review of a ncomplete eapplication, dit ris edetermined lthat uthe [circumstance Apresented, dincluding application;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;

[and](3) Sfl1ºSHPACº(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;»SHPAC»Sfl1 Sfl1º (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;»Sfl1 h u Sfl1º SHPACº(2)»SHPAC SHPACº(3)»SHPAC»Sfl1 » r t h Sfl1º (3)»Sfl1 within ten working days after receipt of a g e l i credentialing application, send a written notification, via h r i s h , United States certified mail, to the applicant requesting any e h t u g information or supporting documentation that the insurer e b l e e , gh requires to approve or deny the credentialing application.

The n d d i = = o h l ] b ,d notice to the applicant shall include a complete and detailed i a º r e r = description of all of the information or supporting tdocumentation erequired wand dthe mname, address and telephone number of a nperson owho dserves mas :the applicant's point of contact for completing the credentialing application process.

b r e t º o t n = .223074.1AIC March 10, 2023 (5:59pm) s k m e - 19 - e a n e d r e l u [ A d 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.

and Sfl1ºSHPACº(3)»SHPAC(4) SHPACº(4)»SHPAC»Sfl1 Sfl1º (4)»Sfl1 no later than thirty Sfl1ºSHPACºdays after receipt of a complete credentialing application,»SHPAC SHPACºcalendar days as described in Paragraph (1) of this subsection or an additional fifteen days as described in Paragraph (2) of this subsection»SHPAC»Sfl1 Sfl1ºdays after receipt of a complete credentialing application»Sfl1 Sfl1º calendar days as described in Paragraph (1) of this subsection or an additional fifteen days as described in Paragraph (2) of this subsection»Sfl1subsection, Sfl1º,»Sfl1 load into the health care plan's provider payment system all provider information, including all information SB 232 Page 17 needed to correctly h u reimburse a newly approved provider according to the provider's » r t h contract.

The health care plan or health care plan's agent g e l i shall add the approved provider's data to the provider h r i s directory upon loading the provider's information into the h , e h t u g health care plan's provider payment system.

e b l e e , gh G.

A health care plan shall reimburse a provider n d d i = = o h for covered health care services for any claims from the l ] b ,d i a º r e r = provider that the insurer receives with a date of service more tthan ethirty wcalendar ddays mafter athe ndate oon thanwhich [forty-fivethe ]health thirtycare calendarplan daysreceived aftera thecomplete datecredentialing onapplication whichfor dthat mprovider :if:

b r e t º o t n = .223074.1AIC March 10, 2023 (5:59pm) s k m e - 20 - e a n e d r e l u [ A d the health care plan received a complete credentialing application for that provider [provided that ] if:

(a) has submitted a complete credentialing application and any supporting documentation that the health care plan has requested in writing within the time frame established in Paragraph SHPACº(3) (2)»SHPAC SHPACº (3)»SHPAC of Subsection F of this section;

[(2)(b) thehas healthno carepast planor hascurrent approved,license sanctions or haslimitations, failedas toreported approveby the New Mexico medical board or deny,another thepertinent applicant'slicensing completeand credentialingregulatory applicationagency, withinor theby timea framesimilar establishedout-of-state pursuantlicensing toand Paragraphregulatory (1)entity offor Subsectiona Fprovider oflicensed thisin section;another state;

(3)and the(c) provider] (b) has noprofessional pastliability orinsurance current license sanctions or limitations,is ascovered reportedunder by the NewMedical MexicoMalpractice medicalAct; board or another pertinent licensing and regulatory agency, or by a similar out-of-state licensing and regulatory entity for a h g provider licensed in another state;

andSB o232 tPage hr18 [(4)and the(2) provider ] g e i k (c) has professional liability insurance h r i s h or is covered under the Medicalhealth Malpracticecare Act;plan:

and(a) ,has t,approved, eor uhas gfailed (2)to approve or deny, the healthapplicant's carecomplete plan:credentialing application within the time frame established pursuant to Paragraph (1) or (2) of Subsection F of this section;

e b l e e h (a) has approved, or has(b) failedfails to nload d d i = = o h approve or deny, the approved applicant's completeinformation credentialinginto l ] b ,d i a º e r i = r application within the timehealth framecare establishedplan's pursuantprovider topayment tsystem ein waccordance dwith m a n o Paragraph (1)(4) SHPACºor (2)»SHPAC of Subsection F of this dsection. m :

b e d s º o t n = .223074.1AIC March 10, 2023 (5:59pm) s k m e - 21 - e a n e d r e l u [ A d section;

or (b) fails to load the approved applicant's information into the health care plan's provider payment system in accordance with Paragraph SHPACº(3)»SHPAC SHPACº (4)»SHPAC of Subsection F of this section.

The superintendent shall adopt and promulgate h g rules to provide for the resolution of disputes relating to o t hr reimbursement and credentialing arising in cases where g e i k credentialing is delayed beyond [forty-five ] thirty days after hSB r232 iPage s19 h application.

, t, e u g K.

A health care plan shall reimburse a provider e b l e e h pursuant to Subsections G, H and I of this section until the n d d i = = o h earlier of the following occurs:

l ] b ,d i a º e r i = r (1) the insurer's approval or denial of the t e w d m a n o provider's complete credentialing application;

or d(2) mthe :passage of three years from the date the health care plan received the provider's complete credentialing application." SB 232 Page 20 25

b e d s º o t n = .223074.1AIC March 10, 2023 (5:59pm) s k m e - 22 - e a n e d r e l u [ A d (2) the passage of three years from the date the health care plan received the provider's complete credentialing application." - 23 - » g o » r h t i k l i g t h s , e h t l i w l b l e e , g n d l h = = b , a l º d i a r e r = , a t e d m a n o d m :

b r e t º o t n = .223074.1AIC March 10, 2023 (5:59pm) s k em e e a n e d r e l u [ A d