NM Insurance Bulletin 2019-001
THE REPORTING REQUIREMENTS OF SECTION 13.10.20.10(D) NMAC
# STATE OF NEW MEXICO
# OFFICE OF SUPERINTENDENT OF INSURANCE
DEPUTY SUPERINTENDENT
Robert E. Doucette, Jr.
OFFICE OF
NEW MEXICO | SUPERINTENDENT
OF INSURANCE
SUPERINTENDENT OF INSURANCE
John G. Franchini
BULLETIN 2019-001
January 3, 2019
DEPUTY SUPERINTENDENT
Bryan E. Brock
FILED
2019 JAN -3 PM 3:42
OF INSURANCE
NM OFFICE OF
SUPERINTENDENT
TO: ALL MAJOR MEDICAL AND DENTAL INSURANCE CARRIERS WITH NETWORKS THAT OFFER OR ADMINISTER HEALTH BENEFITS PLANS IN THIS STATE
RE: THE REPORTING REQUIREMENTS OF SECTION 13.10.28.10(D) NMAC
THE FOLLOWING Bulletin is issued pursuant to NMSA 1978, §§ 59A-2-8, 59A-22-54, 59A-23-14, 59A-46-54, and 59A-47-49; and 13.1.2.8 NMAC and 13.10.28.10 NMAC.
This Bulletin is issued by the Superintendent of Insurance in response to inquiries from health insurance carriers. It provides clarification regarding reporting requirements and an extension to the initial report submission deadline set forth in 13.10.28.10(D) NMAC.
The provider payment and provider credentialing requirements, set forth in 13.10.28.1 et seq. NMAC, establish minimum requirements for carriers' credentialing and re-credentialing processes. Pursuant to 13.10.28.10(D) NMAC, "[e]ach health carrier shall submit a report to the superintendent regarding its credentialing process for the prior two-year period beginning December 31, 2018, and on December 31 for all even numbered years thereafter, or as otherwise directed by the superintendent." However, for the initial report submission, the Superintendent hereby extends the deadline to February 15, 2019, and defines the content and scope of the report as follows:
1. For this reporting cycle, "each type of provider," as referenced in 13.10.28.10(D)(1) and (3) NMAC, shall include:
(a) For major medical insurance carriers:
(1) primary care practitioners ("PCPs");
(2) behavioral health specialists (combined);
Main Office: 1120 Paseo de Peralta, Room 428, Santa Fe, NM 87501
Satellite Office: 6200 Uptown Blvd NE, Suite 100, Albuquerque, NM 87110
Main Phone: (505) 827-4601 | Satellite Phone: (505) 322-2186 | Toll Free: (855) 4 - ASK - OSI
www.osi.state.nm.us
BULLETIN 2019-001
Page | 2
(3) medical/surgical specialists (combined);
(4) doctors of Oriental medicine as defined in NMSA 1978, §§ 61-14A-3(C) and (G); and
(5) laboratory facilities.
(b) For dental insurance carriers: dentists.
2. Where 13.10.28.10(D)(4) NMAC requires “the number of providers terminated for reasons of quality,” major medical insurance carriers shall report the total number of providers as well as the number of each type of provider listed in item 1(a), above.
3. The “amount of time taken to review and reach a determination on an application” shall be the average time taken on all credentialing and re-credentialing applications.
A template for major medical insurance carriers’ initial report is included herewith as Appendix A, and a template for dental insurance carriers’ report as Appendix B. Carriers may use the appropriate template or a reasonable facsimile thereof. Carriers shall file completed reports in SERFF with Filing Type “Informational,” TOI “Network Adequacy,” and Sub-TOI “Provider Credentialing Plan,” with public access allowed.
For the report due on December 31, 2020, and for all subsequent reports by major medical insurance carriers, “each type of provider” as referenced in 13.10.28.10(D)(1) and (3) NMAC shall mean, and data shall be provided for each type of primary care practitioner, each type of facility, and each type of specialist credentialed by a carrier.
If you have questions regarding this Bulletin, please contact Viara Ianakieva, Life and Health Product Filing Bureau, Office of Superintendent of Insurance at (505) 827-4651 or viara.ianakieva@state.nm.us.
DONE and ORDERED this 3rd day of January, 2019.
JOHN G. FRANCHINI
Superintendent of Insurance
Main Office: 1120 Paseo de Peralta, Room 428, Santa Fe, NM 87501
Satellite Office: 6200 Uptown Blvd NE, Suite 100, Albuquerque, NM 87110
Main Phone: (505) 827-4601 | Satellite Phone: (505) 322-2186 | Toll Free: (855) 4 - ASK - OSI
www.osi.state.nm.us
BULLETIN 2019-001
Page | 4
# APPENDIX B:
# TEMPLATE FOR DENTAL INSURANCE CARRIERS'
# PROVIDER CREDENTIALING REPORT
Pursuant to OSI Bulletin 2019-001, carriers shall file completed reports in SERFF with Filing Type “Informational,” TOI “Network Adequacy,” and Sub-TOI “Provider Credentialing Plan,” with public access allowed.
Carrier Name:
Carrier NAIC Number:
Carrier Contact Name:
Carrier Contact Phone Number:
Carrier Contact Email Address:
| Provider Type | No. of applications made | No. of applications approved | No. of applications rejected | Total No. terminated for quality reasons |
| --- | --- | --- | --- | --- |
| Dentists | | | | |
Average number of calendar days taken to approve or deny credentialing applications: _________________
Main Office: 1120 Paseo de Peralta, Room 428, Santa Fe, NM 87501
Satellite Office: 6200 Uptown Blvd NE, Suite 100, Albuquerque, NM 87110
Main Phone: (505) 827-4601 | Satellite Phone: (505) 322-2186 | Toll Free: (855) 4 - ASK - OSI
www.osi.state.nm.us