44th legislature - STATE OF NEW MEXICO - first special session, 1999

RELATING TO HEALTH; ENACTING A NEW SECTION OF CHAPTER 59A, ARTICLE 46 NMSA 1978 TO PROVIDE CERTAIN RIGHTS TO PARTICIPATING PROVIDERS IN THE PROVISION OF HEALTH CARE TO PERSONS HAVING COVERAGE THROUGH HEALTH MAINTENANCE ORGANIZATIONS.

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

Section 1. A new section of Chapter 59A, Article 46 NMSA 1978 is enacted to read:

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

A. As used in this section, "clean claim" means a manually or electronically submitted claim that:

(1) contains all the required data elements necessary for accurate adjudication without the need for additional information from outside of the health maintenance organization's system;

(2) is not materially deficient or improper, including lacking substantiating documentation currently required by the health maintenance organization; or

(3) has no particular or unusual circumstances requiring special treatment that prevents timely payment from being made by the health maintenance organization within thirty days of the date of submittal.

B. A contract between a health maintenance organization and a participating provider shall provide for payment of interest at the rate of one and one-half percent a month, compounded monthly, on:

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

(2) the portion of a claim submitted to the health maintenance organization by the participating provider for payment that is not in dispute and does not require additional information for adjudication if the organization fails to pay the undisputed or substantiated portion of the claim within thirty days of the date of its submittal.

C. If a health maintenance organization is unable to determine liability for or refuses to pay a claim of a participating provider within thirty days of the date of the claim's submittal, that health maintenance organization shall notify the participating provider in writing within thirty days of receipt of the claim of the 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 maintenance organization and a participating provider shall include a clause that has the effect of relieving either party of liability for its actions or inactions.

E. By December 1, 1999, the insurance division shall promulgate rules to require health maintenance organizations to provide timely notice to providers of claims received, whether the claims are submitted electronically or manually by the provider. The rule shall apply to private and governmental plans."