N.M. Admin. Code § 7.5.4.13

Current through Register Vol. 35, No. 21, November 5, 2024

Section 7.5.4.13 - INITIAL ADMINISTRATIVE REVIEW OF INVOICE BY THE DEPARTMENT

A.Each health insurer or group health plan shall have the right to request an initial administrative review of their invoice by the department in the event of a dispute over the invoice amount only. Any other grievances shall be initiated with the office of the superintendent pursuant to their rules. Criteria for the initial administrative review of the invoice shall be available from the department of health immunization program. Any informal hearing or administrative review of the invoice pursuant to the office of the superintendent's rules can only be commenced after the department's initial administrative review of the invoice is completed and the health insurer or group health plan receives notification by mail that the administrative review request has been completed by the department.

B. 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 working 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 the office of the superintendent of insurance.

C. 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.

D. 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. Payment is due regardless of whether the health insurer or group health plan intends to further pursue an administrative review or informal hearing of the invoice with the office of the superintendent or an appeal to district court. Failure to remit payment will result in the department reporting the failure of a health insurer or group health plan to reimburse the department to the office of the attorney general for collection of the invoice amount, including a civil penalty of five hundred dollars ($500) for each day from the date the payment is due.

E. 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. Payment is due regardless of whether the health insurer or group health plan intends to further pursue an administrative review or informal hearing of the invoice with the office of the superintendent or an appeal to district court. Failure to remit payment will result in the department reporting the failure of a health insurer or group health plan to reimburse the department to the office of the attorney general for collection of the invoice amount, including a civil penalty of five hundred dollars ($500) for each day from the date the payment is due.

F.If the health insurer or group health plan continues to dispute the invoice amount, then it may request an informal hearing or administrative review with the office of the superintendent pursuant to the office of the superintendent's rules as authorized by the Vaccine Purchasing Act. The health insurer or group health plan shall notify the immunization program manager if they are pursuing an informal hearing or administrative review of the invoice with the office of the superintendent via email at vpa.fund@state.nm.us.

N.M. Admin. Code § 7.5.4.13

Adopted by New Mexico Register, Volume XXVI, Issue 16, August 28, 2015, eff. 8/28/2015