SB 124 — PHARMACY CLAIM INSURANCE PAYMENT & PROCESS

SENATEAN BILLACT 124RELATING 55THTO LEGISLATUREINSURANCE; - STATEOFNEWMEXICO- FIRST SESSION, 2021 INTRODUCED BY Bill Tallman and Steven P.

NevilleREGULATING ThisTHE documentPROCESSING mayAND incorporatePAYMENT amendmentsOF proposedPHARMACY byCLAIMS. a committee, but not yet adopted, as well as amendments that have been adopted during the current legislative session.

The5 documentBE isIT aENACTED toolBY toTHE showLEGISLATURE amendmentsOF inTHE contextSTATE andOF cannotNEW beMEXICO: used for the purpose of adding amendments to legislation.

hSECTION AN1. ACT g o RELATING TO INSURANCE;

REGULATINGSection THE59A-16-21.1 PROCESSINGNMSA AND1978 PAYMENT(being OFLaws t2000, hrChapter g58, eSection i1, kas PHARMACYamended) CLAIMS.is amended to read:

h"59A-16-21.1. r i s h , t, BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:

eHEALTH uPLAN gREQUIREMENTS.-- eA. b l e e h SECTION 1.

Section 59A-16-21.1 NMSA 1978 (being Laws n d d i = = o h 2000, Chapter 58, Section 1, as amended) is amended to read:

l ] b ,d i a º e "59A-16-21.1.

HEALTH PLAN REQUIREMENTS.-- r i = r t e w d m a n o A.

d(1) m"clean :claim" means a manually or electronically submitted claim from an eligible provider that:

b e d s º o t n = .218659.4AIC February 25, 2021 (10:23am) s k m e e a n e d r e l u [ A d (1) "clean claim" means a manually or electronically submitted claim from an eligible provider that:

and (c) has no particular or unusual circumstances requiring special treatment that prevent payment from being made by the health plan within STBTCºfourteen SHPACºfourteen days of receipt of the claim if submitted electronically by a pharmacy,»SHPAC»STBTC STBTCºfourteen days of receipt of a claim for prescription drugs and related fees if submitted electronically by a pharmacy,»STBTCpharmacy, thirty days of the date of h receipt STBTCºifof submitted electronically»STBTC STBTCºof any g o t hr other electronically submitted claim»STBTCSB STBTCºSHPACºby124 anPage g1 eclaim i k eligible provider other than a pharmacy»SHPAC»STBTC or forty-forty-five h r i s five days if submitted manually;

h , t, e u g (2) "eligible provider" means an individual or e b l e e h entity that:

n d d i = = o h (a) is a participating provider;

l ] b ,d i a º e r i = r (b) a health plan has credentialed after t e w d m a n o assessing and verifying the provider's qualifications;

or d(c) ma :health plan is obligated to reimburse for claims in accordance with the provisions of:

b e d s º o t n = .218659.4AIC February 25, 2021 (10:23am) s k m e - 2 - e a n e d r e l u [ A d (c) a health plan is obligated to reimburse for claims in accordance with the provisions of:

health maintenance organization, nonprofit health care plan, provider service network or third-third-party party payer;

h (1) the amount of a clean claim electronically g o t hr submitted by the eligible provider and not paidSB within124 thirtyPage g2 epaid iwithin kthirty days of the date of receipt and within fourteen days of the h r i s date of receipt STBTCºofof a claim for prescription drugs and h , t, related fees»STBTCfees if the eligible provider is a pharmacy;

and e u g e b l e e h (2) the amount of a clean claim manually n d d i = = o h submitted by the eligible provider and not paid within forty-forty-five l ] b ,d i a º e five days of the date of receipt.

r i = r t e w d m a n o C.

If a health plan is unable to determine dliability mfor :or refuses to pay a claim of an eligible provider within the times specified in Subsection B of this section, the health plan shall make a good-faith effort to notify the eligible provider by fax, electronic or other written communication within fourteen days of receipt of a claim for prescription drugs and related fees if submitted electronically by a pharmacy, thirty days of receipt of any other electronically submitted claim or forty-five days if submitted manually, of all specific reasons why it is not liable for the claim or that specific information is required to determine liability for the claim.

b e d s º o t n = .218659.4AIC February 25, 2021 (10:23am) s k m e - 3 - e a n e d r e l u [ A d liability for or refuses to pay a claim of an eligible provider within the times specified in Subsection B of this section, the health plan shall make a good-faith effort to notify the eligible provider by fax, electronic or other written communication within fourteen days of receipt of STBTCºthe claim»STBTC STBTCºa claim for prescription drugs and related fees»STBTC if submitted electronically by a pharmacy, thirty days of receipt of STBTCºthe claim if submitted electronically by»STBTC STBTCºSHPACºan eligible provider»SHPAC»STBTC STBTCºother than a pharmacy»STBTC STBTCºany other electronically submitted claim»STBTC or forty-five days if submitted manually, of all specific reasons why it is not liable for the claim or that specific information is required to determine liability for the claim.

No contract between a health plan and a participating provider shall include a clause that has the h effect of relieving either party of liability for its actions u » r or inactions.

t h g e l i E.

The office of superintendent of insurance, with h r i s input from interested parties, including health plans andSB h124 ,Page e3 hand eligible providers, shall promulgate rules to require health t u g e b l e e , gh plans to provide:

n d d i = = o h (1) timely eligible provider access to claims l ] b ,d i a º r status information;

e r = t e w d m a n o (2) processes and procedures for submitting dclaims mand :changes in coding for claims;

b r e t º o t n = .218659.4AIC February 25, 2021 (10:23am) s k m e - 4 - e a n e d r e l u [ A d claims and changes in coding for claims;

-SB 5124 -Page »4 g25 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 = .218659.4AIC February 25, 2021 (10:23am) s k em e e a n e d r e l u [ A d