N.M. Admin. Code § 13.10.28.7

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

Section 13.10.28.7 - DEFINITIONS

As used in this rule:

A."Business day" means a consecutive 24-hour period, excluding weekends or holidays.

B."Claim" means a request from a provider for payment for health care services.

C."Clean claim" means a manually or electronically submitted claim from an eligible provider that:

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

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

(3) has no particular or unusual circumstances requiring special treatment - such as, but not limited to, coordination of benefits, pre-existing conditions, subrogation, or suspected fraud - that prevents payment from being made by the health carrier within 30 days of the date of receipt if submitted electronically or 45 days if submitted manually.

D."Completed credentialing application" means a credentialing application that is free of defects and contains all of the information that, when later supplemented by verifications and documentation gathered by the health carrier during the primary source verification process, is necessary for the health carrier to make a credentialing decision.

E."Covered benefits" means the specific health services provided under a health benefits plan.

F."Credentialing" means the process of obtaining and verifying information about a provider and evaluating that provider when that provider applies to become a participating provider within a health carrier's network.

G."Credentialing application" means the application form to be used for the credentialing of providers.

H."Credentialing intermediary" means a person to whom a health carrier has delegated credentialing or re-credentialing authority and responsibility.

I."Date of receipt" means the date on which a claim or credentialing application is deemed received, as follows:

(1) for claims and credentialing applications submitted electronically or sent via fax and unless the sender is notified immediately of a transmission error, the date of receipt is the date on which a claim or credentialing application is submitted or, for claims that arrive on a non-business day, the date of the first business day thereafter;

(2) for claims and credentialing applications that are hand delivered, the date of receipt is the date of delivery; or

(3) for claims and credentialing applications submitted through the US mail, the health carrier may select and shall consistently administer one of the following options:

(a) the first business day following the date of actual receipt by a person or organization that has been designated by the health carrier to manage incoming mail;

(b) if no person or organization has been designated to manage incoming mail, then the first business day following the date of actual receipt by the health carrier; or

(c) three business days after the postmark on the claim or application that is submitted through the US mail.

J."Day" means a calendar day, including weekends, holidays, and any other non-business days.

K."Electronic claim submission" means a request for payment that is submitted by a provider to a health carrier via an electronic portal or using another on-line form or submission process that complies with state and federal patient privacy protection requirements and links or transmits directly to the health carrier.

L."Enrollee or covered person" means an individual who is entitled to receive health care benefits provided by a health carrier for covered health-related services, subject to out-of-network costs, deductibles, co-payments, co-insurance deductibles or other cost-sharing provisions provided by the health benefits plan.

M."Health benefits plan" means a policy, contract, certificate or agreement entered into, offered or issued by a health carrier to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services.

N."Health care professional" means an individual engaged in the delivery of health care services that is licensed or authorized to practice in this state.

O."Health care services" means services, supplies, and procedures for the diagnosis, prevention, treatments, cure or relief of a health condition, illness, injury, or disease, and includes, to the extent offered by the health benefits plan, physical and mental health services, including community-based mental health services, and services for developmental disability or developmental delay.

P."Health insurer or health carrier" means an entity subject to the insurance laws and regulations of this state, including a health insurance company, a health carrier, a health maintenance organization, a hospital and health service corporation, a provider service network, a non-profit health care plan, a third-party, or any other entity that contracts or offers to contract, or enters into agreements to provide, deliver, arrange for, pay for or reimburse any costs of health care services, or that provides, offers or administers health benefit policies and managed health care plans in this state.

Q."Manual claim submission" means a request for payment that is submitted by a provider to a health carrier via US mail, fax, e-mail, or hand delivery.

R."Network" means the group(s) of participating providers who provide services under a network plan or managed health care plan.

S. "Network plan" means a health benefits plan that either requires a covered person to use, or creates incentives, including financial incentives, for a covered person to use health care providers managed, owned, under contract with or employed by the health carrier.

T."Participating provider" means a provider, health care professional, or facility who under express contract with a health carrier or with its contractor or subcontractor, has agreed to provide health care services to enrollees with an expectation of receiving payment directly or indirectly from the health carrier, subject to co-payments, co-insurance deductibles, or other cost-sharing provisions.

U. "Provider" means a physician, hospital or other health care professional licensed or otherwise authorized to furnish health care services in this state.

V."Practice group" means an incorporation or other legal collaboration of providers who work together sharing responsibility for providing care, liability and resources.

W."Provisional acceptance" means a provider that is treated by a health carrier as a participating provider for a period of up to one-year, based on the results of credentialing.

X."Standard reimbursement rate" means the usual, customary and reasonable reimbursement rate paid to providers for health care services that is at or near the median rate paid for similar health care services within the surrounding geographic area where the charges were incurred.

Y."Superintendent" means the superintendent of insurance, acting on behalf of the office of the superintendent, or anyone acting in an official capacity on the superintendent's behalf.

Z. "Uniform credentialing forms" means the version current at the time of the application or re-application process of forms used by the hospital services corporation (HSC), the counsel for affordable quality healthcare datasource (CAQH), or another form as approved by the superintendent provided that the form is used only for the credentialing of facility and ancillary providers, or other credentialing forms as specified by a bulletin posted on the OSI website, including any revisions thereto and as developed and updated from time to time and including electronic versions of such forms.

AA."Verification or verification supporting statement" means documentation confirming the information submitted by an applicant for credentialing by a specifically named entity or by a regional, national, or general data depository providing primary source verification, including but not limited to a college, university, medical school, teaching hospital, specialty certification board, health care facility or institution, state licensing board, federal agency or department, professional liability insurer, or the national practitioner data bank.

N.M. Admin. Code § 13.10.28.7

Adopted by New Mexico Register, Volume XXVII, Issue 16, August 31, 2016, eff. 1/1/2017