HB 402 — HEALTH INSURANCE PROVIDER INFO LOADING

HOUSEAN BILLACT 402RELATING 57THTO LEGISLATUREINSURANCE; - STATE OF NEW MEXICO - FIRST SESSION, 2025 INTRODUCED BY Joshua N.

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TheREQUIRING documentHEALTH isINSURANCE aCARRIERS toolTO toREIMBURSE showAPPROVED amendmentsDENTISTS inAND contextDENTAL andHYGIENISTS cannotIF beTHE usedHEALTH forINSURANCE theCARRIERS purposeFAIL ofTO addingLOAD amendmentsTHAT toINFORMATION legislation.WITHIN THIRTY DAYS OF RECEIVING A COMPLETE CREDENTIALING APPLICATION.

h AN ACT g o RELATING TO INSURANCE;

REQUIRING THE SUPERINTENDENT OF t hr g e i k INSURANCE TO PROMULGATE RULES ESTABLISHING A TIME FRAME FOR h r i s HEALTH INSURANCE CARRIERS TO LOAD INFORMATION ON APPROVED h , t, HHHCºPROVIDERS»HHHC HHHCºDENTISTS»HHHC INTO THEIR PROVIDER e u g e b l e e h PAYMENT SYSTEMS;

REQUIRING HEALTH INSURANCE CARRIERS TO n d d i = = o h REIMBURSE APPROVED HHHCºPROVIDERS»HHHC HHHCºDENTISTS»HHHC IF l ] b ,d i a º e THE HEALTH INSURANCE CARRIERS FAIL TO LOAD THAT INFORMATION r i = r t e w d m a n o WITHIN THIRTY DAYS OF RECEIVING A COMPLETE CREDENTIALING d m :

b e d s º o t n = .229924.1AIC February 26, 2025 (4:17pm) s k m e e a n e d r e l u [ A d APPLICATION.

"[NEW"DENTAL MATERIAL]PLAN--PROVIDER DENTALCREDENTIALING--REQUIREMENTS-- PLAN--DEADLINE.-- HHHCºPROVIDER»HHHC HHHCº DENTIST»HHHC CREDENTIALING-- REQUIREMENTS--DEADLINE.-- A.

The superintendent shall adopt and promulgate rules to provide for a uniform and efficient HHHCºprovider»HHHCprovider HHHCºdentist»HHHC credentialing process.

The superintendent shall approve no more than two forms of application to be used for the credentialing of HHHCºproviders»HHHCdentists HHHCºdentists»HHHCand .dental hygienists.

A health insurance carrier shall not require a HHHCºprovider»HHHCdentist HHHCºdentist»HHHCor dental hygienist to submit information not required by a credentialing application established pursuant to Subsection A of this section.

hHGEIC/HB 402 Page 1 C.

The provisions of this section apply equally to u » r t h initial credentialing applications and applications for g e l i recredentialing.

h r i s D.

The rules that the superintendent adopts and h , e h t u g promulgates shall require primary credential verification no e b l e e , gh more frequently than every three years and allow provisional n d d i = = o h credentialing for a period of one year.

l ] b ,d i a º r e r = E.

Nothing in this section shall be construed to t e w d m a n o require a health insurance carrier to credential or dprovisionally mcredential :a dentist or dental hygienist.

b r e t º o t n = .229924.1AIC February 26, 2025 (4:17pm) s k m e - 2 - e a n e d r e l u [ A d provisionally credential a HHHCºprovider»HHHC HHHCºdentist»HHHC .

(1) assess and verify the qualifications of a HHHCºdentist provider»HHHCor HHHCºdentist»HHHCdental hygienist who is 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 h board, an investigation or a felony conviction, a revocationHGEIC/HB of402 uPage »2 rrevocation of clinical privileges or a denial of insurance coverage, requires t h g e l i additional consideration;

h r i s (3) within ten working days after receipt of a h , e h credentialing application, send a written notification,notification via t u g e b l e e , gh United States certified mail,mail to the applicant requesting any n d d i = = o h information or supporting documentation that the health l ] b ,d i a º r insurance carrier requires to approve or deny the credentialing e r = t e w d m a n o application.

The notice to the applicant shall include a dcomplete mand :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.

b r e t º o t n = .229924.1AIC February 26, 2025 (4:17pm) s k m e - 3 - e a n e d r e l u [ A d 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.

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 health insurance carrier's provider payment system all HHHCºdentist provider»HHHCor HHHCºdentist»HHHCdental hygienist information, including all information needed to correctly reimburse a newly approved HHHCºprovider»HHHCdentist HHHCºdentist»HHHCor dental hygienist according to the HHHCºprovider's»HHHCdentist's HHHCºdentist's»HHHCor dental hygienist's contract.

The health insurance carrier or health insurance carrier's agent h shall add the approved HHHCºprovider's»HHHCdentist's uor »dental rhygienist's HHHCºdentist's»HHHC data to the providerHGEIC/HB directory402 uponPage t3 hprovider gdirectory eupon l i loading the HHHCºprovider's»HHHCdentist's HHHCºdentist's»HHHCor hdental rhygienist's i s information into the health insurance carrier's provider h , e h payment system.

t u g e b l e e , gh G.

A health insurance carrier shall reimburse a ndentist dor ddental ihygienist = = o h HHHCº provider»HHHC HHHCºdentist»HHHC for covered health care lservices ]for bany ,dclaims ifrom athe ºdentist ror servicesdental forhygienist anythat claimsthe fromhealth theinsurance HHHCºprovider»HHHCcarrier ereceives rwith =a tdate eof wservice dmore mthan athirty ncalendar odays HHHCºdentist»HHHCafter thatthe date on which the health insurance carrier receivesreceived da mcomplete :credentialing application for that dentist or dental hygienist if:

b(1) r e t º o t n = .229924.1AIC February 26, 2025 (4:17pm) s k m e - 4 - e a n e d r e l u [ A d with a date of service more than thirty calendar days after the datedentist onor whichdental thehygienist: health insurance carrier received a complete credentialing application for that HHHCº provider»HHHC HHHCºdentist»HHHC if:

(1) the HHHCºprovider»HHHC HHHCºdentist»HHHC :

(b) has no past or current license sanctions or limitations, as reported by the New Mexico HHHCº medical»HHHC board HHHCºofof dental health care»HHHCcare or another pertinent licensing and regulatory agency,agency or by a similar out-of-state licensing and regulatory entity for a hdentist HHHCºor provider»HHHCdental HHHCºdentist»HHHChygienist who is licensed in another g o t hr state;

and g e i k (c) has professional liability insurance h r i s or is covered under the Medical Malpractice Act;

and hHGEIC/HB ,402 t,Page e4 u g (2) the health insurance carrier:

e b l e e h (a) has approved, or has failed to n d d i = = o h approve or deny, the applicant's complete credentialing l ] b ,d i a º e application within the time frame established pursuant to r i = r t e w d m a n o Paragraph (1) or (2) of Subsection F of this section;

or d(b) mfails :to load the approved applicant's information into the health insurance carrier's provider payment system in accordance with Paragraph (4) of Subsection F of this section.

b e d s º o t n = .229924.1AIC February 26, 2025 (4:17pm) s k m e - 5 - e a n e d r e l u [ A d (b) fails to load the approved applicant's information into the health insurance carrier's provider payment system in accordance with Paragraph (4) of Subsection F of this section.

A HHHCºdentist provider»HHHCor HHHCºdentist»HHHCdental hygienist who, at the time services were rendered, was not employed by a practice or group that has contracted with the health insurance carrier to provide services at specified rates of reimbursement shall be paid by the health insurance carrier in accordance with the health insurance carrier's standard reimbursement rate.

A HHHCºdentist provider»HHHCor HHHCºdentist»HHHCdental hygienist who, at the time services were rendered, was employed by a practice or group that has contracted with the health insurance carrier to provide services at specified rates of reimbursement shall be paid by the health insurance carrier in accordance with the terms of that contract.

h J.

The superintendent shall adopt and promulgate g o t hr rules to provide for the resolution of disputes relating to g e i k reimbursement and credentialing arising in cases where h r i s credentialing is delayed beyond thirty days after HGEIC/HB 402 Page 5 application.

h , t, K.