44th legislature - STATE OF NEW MEXICO - second session, 2000

RELATING TO HEALTH; ENACTING A NEW SECTION OF THE HEALTH MAINTENANCE ORGANIZATION LAW TO PROVIDE FOR INTEREST PAYMENTS ON HEALTH PLAN LIABILITIES.

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

Section 1. A new section of the Health Maintenance Organization Law is enacted to read:

"[NEW MATERIAL] PAYMENT OF INTEREST ON CLEAN CLAIMS SUBMITTED BY PARTICIPATING PROVIDER AND NOT PAID WITHIN THIRTY DAYS.--

A. A contract between a health plan and a participating provider shall provide for payment of interest at the rate of one and one-half percent per month, compounded monthly beginning after ninety days of default, on:

(1) the amount of a clean claim electronically submitted by the participating provider and not paid within thirty days of the date of receipt; and

(2) the amount of a clean claim manually submitted by the participating provider and not paid within forty-five days of the date of receipt.

B. If a health plan is unable to determine liability for or refuses to pay a clean claim of a participating provider within the times specified by this section, the health plan shall make a good-faith effort to notify the participating provider by facsimile, electronic or other written communication within thirty days of receipt of the claim, if submitted electronically, or forty-five days, if submitted manually, of the specific reasons why it is not liable for the clean claim or that specific information is required to determine liability for the claim.

C. 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.

D. As used in this section:

(1) "clean claim" means a manually or electronically submitted claim from a participating provider that:

(a) contains 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, and does not lack substantiating documentation currently required by the health plan; or

(c) has no particular or unusual circumstances requiring special treatment that prevent payment from being made by the health plan within thirty days of the date of receipt if submitted electronically, or forty-five days if submitted manually; and

(2) "health plan" means a health maintenance organization, provider service network or third party payer, or any of its agents."