N.M. Admin. Code § 13.10.21.7

Current through Register Vol. 35, No. 23, December 10, 2024

Section 13.10.21.7 - DEFINITIONS

In addition to the following, this rule is subject to the definitions found in 13.10.17 NMAC and to the definitions in 59A-46-2 NMSA 1978 and 59A-46-7 NMSA 1978.

A. "Credentialing" means the process of obtaining and verifying information about a health professional and evaluating that health professional when that health professional applies to become a participating provider with an HMO.

B. "Credentialing intermediary" means a person to whom an HMO has delegated credentialing or recredentialing authority and responsibility.

C. "Health maintenance organization (HMO)" means any person who undertakes to provide or arrange for the delivery of basic health care services to covered persons on a prepaid basis, except for covered person responsibility for copayments or deductibles.

D. "Health care professional" means physicians, dentists, registered nurses, licensed practical nurses, podiatrists, optometrists, chiropractic physicians, physician assistants, nurse anesthetists, certified nurse practitioners, certified nurse-midwives, registered lay midwives, clinical psychologists, social workers, pharmacists, nutritionists, occupational therapists, physical therapists, doctors of oriental medicine, and other professionals engaged in the delivery of health care services who are licensed to practice in New Mexico, are certified, and are practicing under the authority of an HMO.

E. "Primary care practitioner" means physicians, other health care professionals such as doctors of oriental medicine, chiropractic physicians, nurse practitioners, physician assistants, or certified nurse midwives who may provide primary care, provided that the health care practitioner:

1) is acting within his or her scope of practice as defined under the relevant state licensing law;

2) meets the HMO eligibility criteria for health care practitioners who provide primary care; and

3) agrees to participate and to comply with the health care insurers or HMO care coordination and referral policies.

F. "Quality assurance plan" means the internal ongoing quality assurance program of an HMO to monitor and evaluate the HMO's health care services, including its system for credentialing health professionals applying to become a participating provider with an HMO or otherwise providing services to the HMO's covered persons.

G. "Uniform credentialing forms" means the version current at the time of the application or re-application process of forms used either by the hospital services corporation (HSC) or council for affordable quality healthcare universal credentialing datasource (CAQH), including any revisions thereto and as developed and updated from time to time, and including electronic versions of such forms.

H. "Women's health care practitioner" means obstetricians-gynecologists, family practitioners, general practitioners, certified nurse midwives, other physicians specializing in women's health, and physician assistants or nurse practitioners specializing in women's health. An HMO may also make registered lay midwives available to female covered persons for prenatal care and delivery. The HMO may assure that those providers who seek to provide self-referral women's services who are not obstetricians-gynecologists or who are not practicing under the supervision of obstetricians-gynecologists have the requisite background, training, and experience to properly examine and treat self-referred female covered persons.

I. "Written notification" as between the MHCP and providers means a writing delivered through standard U.S. postal service, or through other written means if agreed upon by the parties as effective alternative methods of communication for the intended purpose, including but not limited to personal delivery service, facsimile delivery, or electronic mail.

N.M. Admin. Code § 13.10.21.7

13.10.21.7 NMAC - N, 9/1/2009