N.M. Admin. Code § 13.10.40.9

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

Section 13.10.40.9 - BILLING AND ENFORCEMENT

A.Billing cycle. The department shall send out the invoices to each health insurer and each group health plan for one-fourth of its proportionate share of the estimated amount and reserve calculated pursuant to Subsection B of this Section, as required by Subsection D of Section 25-5A-3 NMSA 1978, according to the following billing cycle:

Billing Cycle	Department's Invoices Date	Insurer's and Group Health Plan's Due Date
July 1 to September 30	September 1	October 1
October 1 to December 31	December 1	January 1
January 1 to March 31	March 1	April 1
April 1 to June 30	June 1	July 1

B.Payment. A health insurer or group health plan shall remit payment to the department's fiscal agent in the manner directed by the department in the invoice, with a corresponding notification of remittance to vpa.fund@state.nm.us.

(1) The annual amount to be reimbursed by each health insurer or group health plan shall be a fraction, the denominator of which is the total number of insured children reported by all health insurers and group health plans and the numerator of which is the number of insured children reported by such health insurer or group health plan, multiplied by the total amount as determined by the department to be expended annually in the corresponding year.

(2) Failure to remit payment within 30 days receipt of the invoice will result in the issuance of a penalty pursuant to Subsection D of Section 24-5A-7 NMSA 1978.

C.Provider prohibition. To avoid duplication of payment, any providers who administer vaccines are prohibited from billing health insurers and group health plans for the cost of any vaccine which was provided to them by the department.

D.Initial review. Each health insurer or group health plan may request an initial administrative review of their invoice by the department in the event of a dispute over the invoice amount.

(1) The health insurer or group health plan may submit a letter requesting an initial administrative review of the invoice and any supporting documents to the immunization program manager or designee within 10 days of receipt of the department's invoice. Such requests shall be submitted to the immunization program manager at P.O. Box 26110, Santa Fe, NM 87502-6110, and via email at vpa.fund@state.nm.us. The health insurer or group health plan shall send a copy of the request to OSI.

(2) Within 10 working days of receipt of the request for an initial administrative review of the invoice, the department of health's immunization program manager or designee shall review the request for an initial administrative review of the invoice and any supporting documents. After the administrative review is complete the department's immunization program manager or designee shall notify the health insurer or group health plan by mail if the invoice amount will remain unchanged or modified.

(a) If a modified invoice is issued by the department then payment is due within five days of receipt of the modified invoice or on the due date identified in the original invoice, whichever is later.

(b) If the invoice remains unchanged then the invoice amount is due within five days of receipt of the department's decision or on the due date identified in the original invoice, whichever is later.

E.Referral. The department shall refer to the superintendent any health insurer or group health plan that has failed to fully reimburse, including any applicable late penalties, the department within 30 days of the date of invoice. Referrals for invoices subject to review as authorized in Subsection D shall be made within 30 days of the department's decision.

F.Notices. Within 10 days of receipt of report of delinquent account, the superintendent shall;

(1) Inform a delinquent health insurer or group health plan of the failure to timely pay the invoice, the invoice amount, the $500 a day civil penalty, calculated from the date payment on the invoice was due, and any applicable interest.

(2) Notices shall be delivered in writing to the group health plan or health insurer's designated contact person, and include instructions about how to remit payment.

(3) The superintendent shall provide a copy of this notice to the department.

G.Interest. Interest on late payments and penalties shall accrue at the post-judgment interest rate in effect at the time of default.

N.M. Admin. Code § 13.10.40.9

Adopted by New Mexico Register, Volume XXXIII, Issue 18, September 27, 2022, eff. 1/1/2023