Provider Credentialing Requirements
Legislation passed in 2016 (SB234) and 2015 (SJC/SB 220) codifies the current Department of Insurance rules that require Managed Care Organizations to credential health care providers within forty-five (45) days of receiving a complete credentialing application. If additional information or supporting documentation is required, the insurer must send a written notice to the provider within ten (10) days of receipt of the application. The current regulation is specific that only two application forms maybe be utilized by the Managed Care Organizations. The bill sets forth penalties for noncompliance, requiring the carrier to pay at the carriers standard rates for any claims with a date of service more than forty-five (45) days after the date on which a complete credentialing application was received by an insurer.
Centennial Care has adopted similar rules that each contracting MCO must follow in order to credential providers.
The Office of the Superintendent of Insurance developed updated regulations (NMAC 13.10.28) based on the 2016 bill which took effect January 1, 2017.
To report problems with credentialing, please complete and return the problem resolution form so that the issue may be documented and addressed. Alternatively, you may call the MHC Bureau at the Office of the Superintendent of Insurance at (505) 827-4645 to initiate an investigation and possible hearing.
NM Hospital Services Corporation, NM Mexico Medical Society, NM Mexico Hospital Association, and the NM Medical Board developed a universal application that is used by most healthcare organizations in the state which is available at https://www.nmhsc.com/credentials-verifications.html.
The CAQH Universal Provider Datasource (UPD) service also meets the data-collection requirements of URAC, the National Committee for Quality Assurance, and the Joint Commission standards.