New Mexico Statutes
Article 16 - Trade Practices and Frauds
Section 59A-16-21.1 - Health plan requirements.

A. As used in this section:
(1) "clean claim" means a manually or electronically submitted claim from an eligible provider that:
(a) contains substantially all the required data elements necessary for accurate adjudication without the need for additional information from outside of the health plan's system;
(b) is not materially deficient or improper, including lacking substantiating documentation currently required by the health plan; and
(c) has no particular or unusual circumstances requiring special treatment that prevent payment from being made by the health plan within fourteen days of receipt of a claim for prescription drugs and related fees if submitted electronically by a pharmacy, thirty days of the date of receipt of any other electronically submitted claim or forty-five days if submitted manually;
(2) "eligible provider" means an individual or entity that:
(a) is a participating provider;
(b) a health plan has credentialed after assessing and verifying the provider's qualifications; or
(c) a health plan is obligated to reimburse for claims in accordance with the provisions of: 1) Subsection G of Section 59A-22-54 NMSA 1978; 2) Subsection G of Section 59A-23-14 NMSA 1978; 3) Subsection G of Section 59A-46-54 NMSA 1978; or 4) Subsection G of Section 59A-47-49 NMSA 1978;
(3) "health plan" means one of the following entities or its agent: health maintenance organization, nonprofit health care plan, provider service network or third-party payer; and
(4) "participating provider" means an individual or entity participating in a health plan's provider network.
B. A health plan shall provide for payment of interest on the plan's liability at the rate of one and one-half percent a month on:
(1) the amount of a clean claim electronically submitted by the eligible provider and not paid within thirty days of the date of receipt and within fourteen days of the date of receipt of a claim for prescription drugs and related fees if the eligible provider is a pharmacy; and
(2) the amount of a clean claim manually submitted by the eligible provider and not paid within forty-five days of the date of receipt.
C. If a health plan is unable to determine 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 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.
D. No contract between a health plan and a participating provider shall include a clause that has the effect of relieving either party of liability for its actions or inactions.
E. The office of superintendent of insurance, with input from interested parties, including health plans and eligible providers, shall promulgate rules to require health plans to provide:
(1) timely eligible provider access to claims status information;
(2) processes and procedures for submitting claims and changes in coding for claims;
(3) standard claims forms; and
(4) uniform calculation of interest.
History: Laws 2000, ch. 58, § 1; 1978 Comp., § 59A-2-9.2, recompiled as § 59A-16-21.1 by Laws 2003, ch. 202, § 15; 2013, ch. 74, § 19; 2016, ch. 20, § 1; 2021, ch. 45, § 1.
Recompilations. — Laws 2003, ch. 202, § 15 recompiled former 59A-2-9.2 NMSA 1978, concerning health plan requirements, as 59A-16-21.1 NMSA 1978, effective June 20, 2003.
The 2021 amendment, effective July 1, 2021, revised certain time limits for health plans to process and pay certain pharmacy claims; in Subsection A, Subparagraph A(1)(c), after "health plan within", added "fourteen days of receipt of a claim for prescription drugs and related fees if submitted electronically by a pharmacy", and after "date of receipt", deleted "if submitted electronically" and added "of any other electronically submitted claim"; in Subsection B, Paragraph B(1), after "date of receipt", added "and within fourteen days of the date of receipt of a claim for prescription drugs and related fees"; and in Subsection C, after "communication within", added "fourteen days of receipt of a claim for prescription drugs and related fees if submitted electronically by a pharmacy", and after "thirty days of receipt of", deleted "the claim if submitted electronically" and added "any other electronically submitted claim".
The 2016 amendment, effective May 18, 2016, provided definitions for "eligible provider" and "participating provider", and amended the definition of "health plan" as used in the New Mexico Insurance Code; in Subsection A, Paragraph (1), after "submitted claim from", deleted "a participating" and added "an eligible", added new Paragraph (2) and redesignated former Paragraph (2) as Paragraph (3), in Paragraph (3), after "means", added "one of the following entities or its agent", after "health maintenance", deleted "organizations" and added "organization, nonprofit health care plan", after "provider service", deleted "networks" and added "network", and after "third-party", deleted "payers or their agents" and added "payer; and", and added new Paragraph (4); in Subsection B, Paragraph (1), after "submitted by the", deleted "participating" and added "eligible", and in Paragraph (2), after "submitted by the", deleted "participating" and added "eligible"; in Subsection C, after "pay a claim of", deleted "a participating" and added "an eligible", and after "notify the", deleted "participating" and added "eligible"; and in Subsection E, deleted "By December 1, 2000", and after "including health plans and", deleted "participating" and added "eligible", and in Paragraph (1), after "timely", deleted "participating" and added "eligible".
Applicability. — Laws 2016, ch. 20, § 7A provided that the provisions of Laws 2016, ch. 20, § 1 apply to claims submitted for payment on or after January 1, 2017.
Temporary provisions. — Laws 2016, ch. 20, § 6 provided that the superintendent of insurance shall promulgate rules to implement the provisions of Laws 2016, ch. 20 no later than September 1, 2016.
The 2013 amendment, effective March 29, 2013, required the superintendent of insurance to promulgate rules for health plans; and in Subsection E, after "December 1, 2000, the", added "office of superintendent of" and after "insurance", deleted "division of the public regulation commission".