SENATE BILL 488

56th legislature - STATE OF NEW MEXICO - first session, 2023

INTRODUCED BY

Gregg Schmedes

AN ACT

RELATING TO HEALTH COVERAGE; ENACTING SECTIONS OF THE NEW MEXICO INSURANCE CODE, THE HEALTH MAINTENANCE ORGANIZATION LAW AND THE NONPROFIT HEALTH CARE PLAN LAW TO LIMIT RETROACTIVE DENIAL OF REIMBURSEMENT TO HEALTH CARE PROVIDERS.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:

     SECTION 1. A new section of Chapter 59A, Article 22 NMSA 1978 is enacted to read:

     "[NEW MATERIAL] RETROACTIVE DENIAL OF REIMBURSEMENT TO HEALTH CARE PROVIDERS--TIME LIMITATIONS.--

          A. An insurer may only retroactively deny reimbursement to a health care provider for a claim if:

                (1) fewer than six months have passed since the insurer paid the health care provider for the claim; or

                (2) the claim was subject to coordination of benefits with another insurer and fewer than eighteen months have passed since the insurer paid the health care provider for the claim.

          B. The time limitations provided in this section shall not apply to retroactive denial of reimbursement to a health care provider when:

                (1) the information submitted to the insurer was fraudulent;

                (2) the claim was improperly coded; or

                (3) the claim submitted to the insurer was a duplicate."

     SECTION 2. A new section of Chapter 59A, Article 23 NMSA 1978 is enacted to read:

     "[NEW MATERIAL] RETROACTIVE DENIAL OF REIMBURSEMENT TO HEALTH CARE PROVIDERS--TIME LIMITATIONS.--

          A. An insurer may only retroactively deny reimbursement to a health care provider for a claim if:

                (1) fewer than six months have passed since the insurer paid the health care provider for the claim; or

                (2) the claim was subject to coordination of benefits with another insurer and fewer than eighteen months have passed since the insurer paid the health care provider for the claim.

          B. The time limitations provided in this section shall not apply to retroactive denial of reimbursement to a health care provider when:

                (1) the information submitted to the insurer was fraudulent;

                (2) the claim was improperly coded; or

                (3) the claim submitted to the insurer was a duplicate."

     SECTION 3. A new section of the Health Maintenance Organization Law is enacted to read:

     "[NEW MATERIAL] RETROACTIVE DENIAL OF REIMBURSEMENT TO PROVIDERS--TIME LIMITATIONS.--

          A. A carrier may only retroactively deny reimbursement to a provider for a claim if:

                (1) fewer than six months have passed since the carrier paid the provider for the claim; or

                (2) the claim was subject to coordination of benefits with another carrier and fewer than eighteen months have passed since the carrier paid the provider for the claim.

          B. The time limitations provided in this section shall not apply to retroactive denial of reimbursement to a provider when:

                (1) the information submitted to the carrier was fraudulent;

                (2) the claim was improperly coded; or

                (3) the claim submitted to the carrier was a duplicate."

     SECTION 4. A new section of the Nonprofit Health Care Plan Law is enacted to read:

     "[NEW MATERIAL] RETROACTIVE DENIAL OF REIMBURSEMENT TO PROVIDERS--TIME LIMITATIONS.--

          A. A health care plan may only retroactively deny reimbursement to a provider for a claim if:

                (1) fewer than six months have passed since the health care plan paid the provider for the claim; or

                (2) the claim was subject to coordination of benefits with another health care plan and fewer than eighteen months have passed since the health care plan paid the provider for the claim.

          B. The time limitations provided in this section shall not apply to retroactive denial of reimbursement to a provider when:

                (1) the information submitted to the health care plan was fraudulent;

                (2) the claim was improperly coded; or

                (3) the claim submitted to the health care plan was a duplicate."

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