House Bill 402

     "[NEW MATERIAL] DENTAL PLAN--PROVIDER CREDENTIALING-- REQUIREMENTS--DEADLINE.--

          A. The superintendent shall adopt and promulgate rules to provide for a uniform and efficient provider credentialing process. The superintendent shall approve no more than two forms of application to be used for the credentialing of dentists and dental hygienists.

          B. A health insurance carrier shall not require a dentist or dental hygienist to submit information not required by a credentialing application established pursuant to Subsection A of this section.

          C. The provisions of this section apply equally to initial credentialing applications and applications for recredentialing.

          D. The rules that the superintendent adopts and promulgates shall require primary credential verification no more frequently than every three years and allow provisional credentialing for a period of one year.

          E. Nothing in this section shall be construed to require a health insurance carrier to credential or provisionally credential a dentist or dental hygienist.

          F. The rules that the superintendent adopts and promulgates shall establish that a health insurance carrier or a health insurance carrier's agent shall:

                (1) assess and verify the qualifications of a dentist or dental hygienist who is applying to become a participating provider within thirty calendar days of receipt of a complete credentialing application and issue a decision in writing to the applicant approving or denying the credentialing application;

                (2) be permitted to extend the credentialing period to assess and issue a determination by an additional fifteen calendar days if, upon review of a complete application, it is determined that the circumstance presented, including an admission of sanctions by the state licensing board, an investigation or a felony conviction, a revocation of clinical privileges or a denial of insurance coverage, requires additional consideration;

                (3) within ten working days after receipt of a credentialing application, send a written notification via United States certified mail to the applicant requesting any information or supporting documentation that the health insurance carrier requires to approve or deny the credentialing application. The notice to the applicant shall include a complete and detailed description of all of the information or supporting documentation required and the name, address and telephone number of a person who serves as the applicant's point of contact for completing the credentialing application process. Any information required pursuant to this section shall be reasonably related to the information in the application; and

                (4) no later than thirty calendar days as described in Paragraph (1) of this subsection or an additional fifteen days as described in Paragraph (2) of this subsection, load into the health insurance carrier's provider payment system all dentist or dental hygienist information, including all information needed to correctly reimburse a newly approved dentist or dental hygienist according to the dentist's or dental hygienist's contract. The health insurance carrier or health insurance carrier's agent shall add the approved dentist's or dental hygienist's data to the provider directory upon loading the dentist's or dental hygienist's information into the health insurance carrier's provider payment system.

          G. A health insurance carrier shall reimburse a dentist or dental hygienist for covered health care services for any claims from the dentist or dental hygienist that the health insurance carrier receives with a date of service more than thirty calendar days after the date on which the health insurance carrier received a complete credentialing application for that dentist or dental hygienist if:

                (1) the dentist or dental hygienist:

                     (a) has submitted a complete credentialing application and any supporting documentation that the health insurance carrier has requested in writing within the time frame established in Paragraph (3) of Subsection F of this section;

                     (b) has no past or current license sanctions or limitations, as reported by the New Mexico board of dental health care or another pertinent licensing and regulatory agency or a similar out-of-state licensing and regulatory entity for a dentist or dental hygienist who is licensed in another state; and

                     (c) has professional liability insurance or is covered under the Medical Malpractice Act; and

                (2) the health insurance carrier:

                     (a) has approved, or has failed to approve or deny, the applicant's complete credentialing application within the time frame established pursuant to Paragraph (1) or (2) of Subsection F of this section; or

                     (b) fails to load the approved applicant's information into the health insurance carrier's provider payment system in accordance with Paragraph (4) of Subsection F of this section.

          H. A dentist or dental hygienist who, at the time services were rendered, was not employed by a practice or group that has contracted with the health insurance carrier to provide services at specified rates of reimbursement shall be paid by the health insurance carrier in accordance with the health insurance carrier's standard reimbursement rate.

          I. A dentist or dental hygienist who, at the time services were rendered, was employed by a practice or group that has contracted with the health insurance carrier to provide services at specified rates of reimbursement shall be paid by the health insurance carrier in accordance with the terms of that contract.

          J. The superintendent shall adopt and promulgate rules to provide for the resolution of disputes relating to reimbursement and credentialing arising in cases where credentialing is delayed beyond thirty days after application.

          K. A health insurance carrier shall reimburse a dentist or dental hygienist pursuant to Subsections G, H and I of this section until the earlier of the following occurs:

                (1) the health insurance carrier's approval or denial of the dentist's or dental hygienist's complete credentialing application; or

                (2) the passage of three years from the date the health insurance carrier received the dentist's or dental hygienist's complete credentialing application.

          L. As used in this section:

                (1) "credentialing" means the process of obtaining and verifying information about a dentist or dental hygienist and evaluating that dentist or dental hygienist when that dentist or dental hygienist seeks to become a participating provider;

                (2) "dental hygienist" means an individual who has graduated and received a degree from a dental hygiene educational program that is accredited by the commission on dental accreditation, provides a minimum of two academic years of dental hygiene curriculum and is an institution of higher education; and "dental hygienist" means, except as the context otherwise requires, an individual who holds a license to practice dental hygiene in New Mexico; and

                (3) "dentist" means a person who has graduated and received a degree from a school of dentistry that is accredited by the commission on dental accreditation and holds a license to practice dentistry in New Mexico."

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