TITLE 8 SOCIAL
SERVICES
CHAPTER 308 MANAGED
CARE PROGRAM
PART 2 PROVIDER NETWORK
8.308.2.1 ISSUING
AGENCY: New Mexico Health Care Authority.
[8.308.2.1 NMAC -
Rp, 8.308.2.1 NMAC, 5/1/2018;
A, 7/1/2024]
8.308.2.2 SCOPE: This rule applies to the general
public.
[8.308.2.2 NMAC -
Rp, 8.308.2.2 NMAC, 5/1/2018]
8.308.2.3 STATUTORY
AUTHORITY: The New Mexico medicaid
program and other health care programs are administered pursuant to regulations
promulgated by the federal department of health and human services under Title
XIX of the Social Security Act as amended or by state statute. See Section 27-1-12 et seq., NMSA 1978. Section 9-8-1 et seq. NMSA 1978 establishes the health care
authority (HCA) as a single, unified department to administer laws and exercise
functions relating to health care facility licensure and health care purchasing
and regulation.
[8.308.2.3 NMAC -
Rp, 8.308.2.3 NMAC, 5/1/2018; A, 7/1/2024]
8.308.2.4 DURATION: Permanent.
[8.308.2.4 NMAC -
Rp, 8.308.2.4 NMAC, 5/1/2018]
8.308.2.5 EFFECTIVE
DATE: May 1, 2018, unless a later date is cited at
the end of a section.
[8.308.2.5 NMAC -
Rp, 8.308.2.5 NMAC, 5/1/2018]
8.308.2.6 OBJECTIVE: The objective of this rule is to provide
instructions for the service portion of the New Mexico medical assistance
division programs.
[8.308.2.6 NMAC -
Rp, 8.308.2.6 NMAC, 5/1/2018]
8.308.2.7 DEFINITIONS: [RESERVED]
8.308.2.8 [RESERVED]
[8.308.2.8 NMAC -
Rp, 8.308.2.8 NMAC, 5/1/2018]
8.308.2.9 GENERAL
REQUIREMENTS: The HSD managed care organization (MCO) shall
establish and maintain a comprehensive network of providers and required
specialists in sufficient numbers to make all services included in the benefit
package available in accordance with access standards. The MCO shall require any contracted provider
to be enrolled through a fully executed provider participation agreement (PPA)
with HSD’s medical assistance division (MAD).
In completing the PPA, the provider may choose to participate only in
managed care, only in fee-for-service, or both.
Providers who have completed a PPA can choose to pursue contracting with
one or more MCOs but do not have to contract with all MCOs. The MCO shall refer any provider who notifies
the MCO of a change in his or her location, licensure, certification, or status
to the MAD provider web portal to update his or her provider information. In addition, the MCO shall provide an e-mail notification
to MAD regarding changes in provider servicing location; change in licensure or
certification; and the date on which the provider is no longer participating
with the MCO, including the reason.
A. Required MCO
policies and procedures:
(1) Pursuant
to section 1932(b)(7) of the Social Security Act, and consistent with 42 CFR
438.12, the MCO shall not discriminate against a provider that serves high-risk
populations or specializes in conditions that require costly treatment.
(2) The
MCO shall not discriminate with respect to participation, reimbursement, or
indemnification of any provider acting within the scope of his or her
provider’s license or certification under applicable state statute or rule
solely on the basis of the provider’s license or
certification.
(3) The
MCO shall upon declining to include an individual or a
group of providers in its network, give the affected provider written notice of
the reason for the MCO decision.
(4) The
MCO shall conduct screenings of all subcontractors and contract providers in
accordance with the Employee Abuse Registry Act, 27-7A-3 NMSA 1978, the New
Mexico Caregivers Criminal History Screening Act, 2-17-2 et seq., NMSA 1978 and
7.1.9 NMAC, the New Mexico Children’s and Juvenile Facility Criminal Records
Screening Act, 32A-15-1 to 32A-15-4 NMSA 1978, Patient Protection and
Affordable Care Act (PPACA), and ensure that all subcontracted and contracted
providers are screened against the federal “list of excluded individuals or entities”
(LEIE) and the federal “excluded parties list system” (EPLS) (now known as the
system for award management (SAM)) and any other databases that may be required
through federal or state regulation.
(5) The
MCO shall require that any provider, including a provider making a referral or
ordering a covered service, have a national provider identifier (NPI) unless
the provider is an atypical provider as defined by the centers for medicare and medicaid services
(CMS).
(6) The
MCO shall require that each provider billing for or rendering services to a MCO
member has a unique identifier in accordance with the provisions of Section
1173(b) of the Social Security Act.
(7) The
MCO shall consider in establishing and maintaining the network of appropriate
providers its:
(a) anticipated
enrollment;
(b) numbers
of contracted providers who are not accepting new patients; and
(c) geographic
locations of contracted providers and members, considering distance, travel
time, the means of transportation ordinarily used by members; and whether the
location provides physical access for members with disabilities.
(8) The
MCO shall ensure that a contracted provider offers hours of operation that are
no less than the hours of operation offered to its commercial enrollees.
(9) The
MCO shall establish mechanisms such as notices or training materials to ensure
that a contracted provider comply with the timely
access requirements, monitor such compliance regularly, and take corrective
action if there is a failure to comply.
(10) The
MCO shall provide to its members and contracted
providers clear instructions on how to access covered services, including those
that require prior approval and referral.
(11) The
MCO shall ensure that all contracted providers meet all availability; time and
distance standards set by HSD, and have a system to
track and report this data.
(12) The
MCO shall provide access to a non-contracted provider if the MCO is unable to
provide covered benefits covered under its agreement with HSD in an adequate
and timely manner to a member and continue to authorize the use of a
non-contracted provider for as long as the MCO is unable to provide these
services through its contracted providers.
The MCO must ensure that the cost to its members utilizing a
non-contracted provider is not greater than it would be if the service was
provided within the MCO’s network.
B. Health services
contracting: Contracts with an
individual and an institutional provider shall mandate compliance with the MCOs
quality management (QM) and quality improvement (QI) programs.
C. Provider
qualifications and credentialing: The
MCO shall verify that each contracted or subcontracted provider (practitioner
or facility) participating in, or employed by, the MCO meets applicable federal
and state requirements for licensing, certification, accreditation and
re-credentialing for the type of care or services within the scope of practice
as defined by federal and state statutes, regulations, and rules.
D. Utilization of
out-of-state providers: To the extent
possible, the MCO is encouraged to utilize in-state and border providers, which
are defined as those providers located within 100 miles of the New Mexico
border, Mexico excluded. The MCO may
include out-of-state providers in its network.
All services must be rendered within the boundaries of the United
States. No payment is allowed to any
financial institution or entity located outside of the United States.
E. Provider
lock-in: HSD shall allow the MCO to
require that a member see a certain provider while ensuring reasonable access
to quality services when identification of utilization of unnecessary services
or the member’s behavior is detrimental or indicates a need to provide case
continuity. Prior to placing a member on
a provider lock-in, the MCO shall inform the member of its intent to lock-in,
including the reasons for imposing the provider lock-in and that the
restriction does not apply to emergency services furnished to the member. The MCO’s grievance procedure shall be made
available to a member disagreeing with the provider lock-in. The member shall be removed from provider
lock-in when the MCO has determined that the utilization problems or
detrimental behavior have ceased and that recurrence
of the problems is judged to be improbable.
HSD shall be notified of provider lock-ins and provider lock-in removals
at the time they occur as well as receiving existing lock-in information on a
quarterly basis.
F. Pharmacy
lock-in: HSD shall allow the MCO to
require that its member see a certain pharmacy provider when the member’s
compliance or drug seeking behavior is suspected. Prior to placing the member on pharmacy
lock-in, the MCO shall inform the member of the intent to lock-in. The MCO’s grievance procedure shall be made
available to a member being designated for pharmacy lock-in. The member shall be removed from pharmacy
lock-in when the MCO has determined that the compliance or drug seeking
behavior has been resolved and the recurrence of the problem is judged to be
improbable. HSD shall be notified of all
provider lock-ins and provider lock-in removals at the time they occur as well
as receiving existing lock-in information on a quarterly basis.
[8.308.2.9 NMAC -
Rp, 8.308.2.9 NMAC, 5/1/2018]
8.308.2.10 PRIMARY
CARE PROVIDER (PCP): The MCO shall ensure that each member is
assigned a primary care provider (PCP), except a member that is dually eligible
for medicare and medicaid
(dual eligible). The PCP shall be a
provider identified in Subsection A below, participating in the MCO’s network
who will assume the responsibility for supervising, coordinating, and providing
primary health care to its member, initiating referrals for specialist care,
and maintaining the continuity of the member’s care. For a dual-eligible member, the MCO will be
responsible for coordinating the primary, acute, behavioral health and long-term
care services with the member’s medicare PCP.
A. Types of PCPs: The MCO shall designate the following types
of providers as a PCP as appropriate:
(1) medical
doctors or doctors of osteopathic medicine with the
following specialties: general practice,
family practice, internal medicine, gerontology, gynecology and pediatrics;
(2) certified
nurse practitioners, certified nurse midwives and physician assistants;
(3) specialists,
on an individual basis, for members whose care is more appropriately managed by
a specialist, such as members with infectious diseases, chronic illness,
complex behavioral health conditions, or disabilities;
(4) a
primary care team consisting of residents and a supervising faculty physician
for contracts with teaching facilities or teams that include mid-level
practitioners who, at the member’s request, may serve as the point of first
contact; in both instances the MCO shall
organize its team to ensure continuity of care to the member and shall identify
a “lead physician” within the team for each member; the “lead physician” shall
be an attending physician; medical students, interns and residents may not
serve as “lead physicians”;
(5) federally
qualified health centers (FQHC), rural health clinics (RHC), or Indian health
service (IHS), tribal health providers, and urban Indian providers (I/T/U); or
(6) other
providers that meet the credentialing requirements for PCPs.
B. Selection of or
assignment to a PCP: The MCO shall
maintain and implement written policies and procedures governing the process of
member selection of a PCP and requests for change.
(1) Initial
enrollment: At the time of enrollment,
the MCO shall ensure that each member has the freedom to choose a PCP within a
reasonable distance from his or her place of residence.
(2) Subsequent
change in PCP initiated by a member: the
MCO shall allow its member to change his or her PCP at any time for any
reason. The request can be made in
writing or verbally via telephone:
(a) if
a request is made on or before the 20th calendar day of the month, the change
shall be effective as the first of the following month;
(b) if
a request is made after the 20th calendar day of the month, the change shall be
effective the first calendar day of the second month following the request.
(3) A
subsequent change in PCP initiated by the MCO:
The MCO may initiate a PCP change for its member under the following circumstances:
(a) the
member and the MCO agree that assignment to a difference PCP in the MCO’s
provider network is in the member’s best interest, based on the member’s
medical condition;
(b) a
member’s PCP ceases to be a contracted provider;
(c) a
member’s behavior toward his or her PCP is such that it is not feasible to
safely or prudently provide medical care and the PCP has made reasonable
efforts to accommodate the member;
(d) a
member has initiated legal actions against the PCP; or
(e) the
PCP is suspended for any reason.
(4) The
MCO shall make a good faith effort to give written notice of termination of a
contracted provider, within 15 calendar days after receipt or issuance of the
termination notice, to each member who received his or her primary care from or
was seen on a regular basis by the terminated provider. In such instances, the MCO shall allow
affected members to select a PCP or the MCO shall make an assignment within 15
calendar days of the termination effective date.
[8.308.2.10 NMAC -
Rp, 8.308.2.10 NMAC, 5/1/2018]
8.308.2.11 STANDARDS
FOR ACCESS: The MCO shall establish and follow protocols
to ensure the accessibility, availability and referral to health care providers
for each medically necessary service to its members. The MCO shall provide access to the full
array of covered services within the benefit package. If a service is unavailable based on the
access guidelines, a service equal to or higher than that service shall be
offered.
A. Access to urgent
and emergency services: Services for
emergency conditions provided by physical and behavioral health providers,
including emergency transportation, urgent conditions, and post-stabilization
care shall be covered by the MCO (only within the United States for both
physical and behavioral health). An
urgent condition exists when a member manifests acute symptoms and signs that,
by reasonable medical judgment, represent a condition of sufficient severity
that the absence of medical attention within 24 hours could reasonably result
in an emergency condition. Serious
impairment of biopsychosocial functioning, imminent out-of-home placement for
child and adolescent members or serious jeopardy to the behavioral health of
the member are considered urgent conditions.
An emergency condition exists when a member manifests acute symptoms and
signs that, by reasonable lay person judgment, represent a condition of
sufficient severity that the absence of immediate medical attention, including
behavioral health treatment, could reasonably result in death, serious
impairment of bodily function or major organ or serious jeopardy to the overall
health of the member or with respect to a pregnant woman, the health of the
woman or her unborn child, in serious jeopardy.
Post-stabilization care means covered services related to an emergency
medical or behavioral health condition, that are provided after the member is
stabilized in order to maintain the stabilized
condition and may include improving or resolving the member’s condition.
(1) The
MCO shall ensure that there is no clinically significant delay caused by the
MCO’s utilization control measures.
Prior authorization is not required for emergency services in or out of
the MCO’s network, and all emergency services shall be reimbursed at the HSD
approved rate. The MCO shall not
retroactively deny a claim for an emergency screening examination because the
condition, which appeared to be an emergency medical or behavioral health condition
under the prudent layperson standard, turned out to be non-emergent in nature.
(2) The
MCO shall ensure that the member has the right to use any hospital or other
licensed emergency setting for emergency care, regardless of whether the
provider is contracted with the MCO.
(3) The
MCO shall ensure that the member has access to the nearest appropriately
designated trauma center according to established emergency medical standards
(EMS) triage and transportation protocols.
B. PCP
availability: The MCO shall follow a
process that ensures a sufficient number of PCPs are
available to allow members a reasonable choice among providers.
(1) The
MCO shall have at least one PCP available per 2,000 members and not more than
2,000 members are assigned to a single provider unless approved by HSD.
(2) The
MCO must ensure that members have adequate access to specialty providers.
(3) The
minimum number of PCPs from which to choose and the distances to those
providers shall vary by county based on whether the county is urban, rural or
frontier. Urban counties are:
Bernalillo, Los Alamos, Santa Fe and Dona Ana.
Frontier counties are: Catron, Harding, DeBaca, Union, Guadalupe,
Hidalgo, Socorro, Mora, Sierra, Lincoln, Torrance, Colfax, Quay, San Miguel and
Cibola. Rural counties are those that
are not urban or frontier. The standards
are as follows:
(a) ninety
percent of urban member residents shall travel no farther than 30 miles;
(b) ninety
percent of rural member residents shall travel no farther than 45 miles; and
(c) ninety
percent of frontier member residents shall travel no farther than 60 miles.
C. Pharmacy provider
availability: The MCO shall ensure that a sufficient number of pharmacy providers are available to
its members. The MCO shall ensure that
pharmacy services meet geographic access standards based on its member’s county
of residence. The access standards are
as follows:
(1) ninety
percent of urban residents shall travel no farther than 30 miles;
(2) ninety
percent of rural residents shall travel no farther than 45 miles; and
(3) ninety
percent of frontier residents shall travel no farther than 60 miles.
D. For all other
provider types, including, but not limited to behavioral health providers,
physical health providers, long term care providers, hospitals and
transportation providers, as directed by MAD, the following standards shall
apply:
(1) ninety
percent of urban residents shall travel no farther than 30 miles;
(2) ninety
percent of rural residents shall travel no farther than 60 miles, unless this
type of provider is not physically present in the prescribed radius or unless
otherwise exempted by MAD; and
(3) ninety
percent of frontier residents shall travel no farther than 90 miles, unless
this type of provider is not physically present in the prescribed radius or
unless otherwise exempted by MAD.
E. The MCO must
provide transportation as necessary to meet the standards of access.
[8.308.2.11 NMAC -
Rp, 8.308.2.11 NMAC, 5/1/2018]
8.308.2.12 ACCESS
TO HEALTH CARE SERVICES: The MCO shall
ensure that there are a sufficient number of PCPs and dentists available to
members to allow members a reasonable choice, and
ensure that there are a sufficient number of behavioral health providers, based
on the least restrictive, medically necessary needs of its members, available
statewide to members to allow members a reasonable choice.
A. The MCO shall
report to HSD all provider groups, health centers and individual physician
practices and sites in its network that are not accepting new MCO members.
B. For routine,
asymptomatic, member-initiated, outpatient appointments for primary medical
care, the request-to-appointment time shall be no more than 30 calendar days,
unless the member requests a later time.
C. For routine
asymptomatic member-initiated dental appointments the request-to-appointment
time shall be no more than 60 calendar days unless the member requests a later
date.
D. For routine,
symptomatic, member-initiated, outpatient appointments for non-urgent primary
medical and dental care, the request-to-appointment time shall be no more than
14 calendar days, unless the member requests a later time.
E. For non-urgent
behavioral health care, the request-to-appointment time shall be no more than
14 calendar days, unless the member requests a later time.
F. Primary medical,
dental and behavioral health care outpatient appointments for urgent conditions
shall be available within 24 hours.
G. For specialty
outpatient referral and consultation appointments, excluding behavioral health,
which is addressed in Subsection E of this Section, the request-to-appointment
time shall generally be consistent with the clinical urgency, but no more than
21 calendar days, unless the member requests a later time.
H. For routine
outpatient diagnostic laboratory, diagnostic imaging and other testing
appointments, the request-to-appointment time shall be consistent with the
clinical urgency, but no more than 14 calendar days, unless the member requests
a later time.
I. For outpatient diagnostic
laboratory, diagnostic imaging and other testing, if a “walk-in” rather than an
appointment system is used, the member wait time shall be consistent with
severity of the clinical need.
J. For urgent
outpatient diagnostic laboratory, diagnostic imaging and other testing,
appointment availability shall be consistent with the clinical urgency, but no
longer than 48 hours.
K. The timing of
scheduled follow-up outpatient visits with practitioners shall be consistent
with the clinical need.
L. The in-person
prescription fill time (ready for pickup) shall be no longer than 40
minutes. A prescription phoned in by a
practitioner shall be filled within 90 minutes.
M. The MCO’s
preferred drug list (PDL) shall follow HSD guidelines for services and items included
in the managed care benefit package, pharmacy services.
N. Access to durable
medical equipment: The MCO shall approve
or deny a request for new durable medical equipment (DME) or for repairs to
existing DME owned or rented by the member within seven working days of the
request date.
(1) All
new customized or made-to-measure DME or customized modifications to existing
DME owned or rented by the member shall be delivered to the member within 150
calendar days of the request date.
(2) All
standard DME shall be delivered within 24 hours of the request, if needed on an
urgent basis.
(3) All
standard DME not needed on an urgent basis shall be delivered within a time
frame consistent with clinical need.
(4) All
DME repairs or non-customized modifications shall be delivered within 60
calendar days of the request date.
(5) The
MCO shall have an emergency response plan for non-customized DME needed on an emergent basis.
(6) The
MCO shall ensure that its member and his or her family or caretaker receive
proper instruction on the use of DME provided by the MCO or its subcontractor.
O. Access to
prescribed medical supplies: The MCO
shall approve or deny a request for prescribed medical supplies within seven
working days of the request date. The
MCO shall ensure that:
(1) a
member can access prescribed medical supplies within 24 hours when needed on an
urgent basis;
(2) a
member can access routine medical supplies within a time frame consistent with
the clinical need;
(3) subject
to any requirements to procure a PCP order to provide supplies to its members,
members utilizing medical supplies on an ongoing basis shall submit to the MCO
lists of needed supplies monthly; and the MCO or its subcontractor shall
contact the member if the requested supplies cannot be delivered in the time
frame expected and make other delivery arrangements consistent with clinical
need; and
(4) the
MCO shall ensure that its member and his or her family receive proper
instruction on the use of medical supplies provided by the MCO or its
subcontractors.
P. Access to
transportation services: The MCO shall
provide the transportation benefit for medically
necessary physical and behavioral health.
The MCO shall have sufficient transportation providers available to meet
the needs of its members, including an appropriate number of handivans available for members who are wheelchair or
ventilator dependent or have other equipment needs. The MCO shall develop and implement policies
and procedures to ensure that:
(1) transportation
arranged is appropriate for the member’s clinical condition;
(2) the
history of services is available at the time services are requested to expedite
appropriate arrangements;
(3) CPR-certified
drivers are available to transport members consistent with clinical need;
(4) the
transportation type is clinically appropriate, including access to
non-emergency ground ambulance carriers;
(5) members
can access and receive authorization for medically necessary transportation
services under certain unusual circumstances without advance notification; and
(6) minor
aged members are accompanied by a parent or legal guardian as indicated to
provide safe transportation. See 8.301.6
NMAC for a detailed description of attendant coverage for a member 18 years of
age and older.
Q. Use of
technology: The MCO is encouraged to use
technology, such as telemedicine, to ensure access and availability of services
statewide.
R. For behavioral
health crisis services, face-to-face appointments shall be available within two
hours.
[8.308.2.12 NMAC -
Rp, 8.308.2.12 NMAC, 5/1/2018]
8.308.2.13 SPECIALTY
PROVIDERS: The MCO shall contract with
a sufficient number of specialists with the applicable
range of expertise to ensure that the needs of the members are met within the
MCO’s provider network. The MCO shall
also have a system to refer members to non-contracted providers if providers
with the necessary qualifications or certifications do not participate in the
network. Out-of-network providers must
coordinate with the MCO with respect to payment. The MCO must ensure that cost
to its member is no greater than it would be if the services were furnished
within the network.
[8.308.2.13 NMAC -
Rp, 8.308.2.13 NMAC, 5/1/2018]
8.308.2.14 FAMILY
PLANNING PROVIDERS:
A. The MCO shall
give each adolescent and adult member the opportunity to use his or her own PCP
or to use any family planning provider for family planning services without
requiring a referral. Each female member
shall also have the right to self-refer to a contracted women’s health
specialist for covered services necessary to provide women’s routine and
preventive health services. This right
to self-refer is in addition to the member’s designated source of primary care
if that source is not a women’s health specialist. Family planning providers, including those
funded by Title X of the public health service, shall be reimbursed by the MCO
for all covered family planning services, regardless of whether they are
contracted providers of the member’s MCO.
Unless otherwise negotiated, the MCO shall reimburse providers of family
planning services pursuant to the medicaid fee
schedule.
B. Pursuant to state
statute and rule, a non-contracted provider is responsible for keeping family
planning information confidential in favor of the individual member even if the
member is a minor. The MCO is not responsible
for the confidentiality of medical records maintained by a non-contracted provider, but shall notify the non-contracted provider of
the confidentiality provisions contained herein.
[8.308.2.14 NMAC -
Rp, 8.308.2.14 NMAC, 5/1/2018]
8.308.2.15 INDIAN
HEALTH SERVICES, TRIBAL HEALTHCARE, AND URBAN INDIAN PROVIDERS (I/T/U):
A. The MCO shall
make best efforts to contract with I/T/Us in the state, including, but not
limited to, contracting for such services as transportation, care coordination
and case management. The MCO is
encouraged to use the sample I/T/U addendum as described in 42 CFR 438.14 to
develop an addendum specific to New Mexico that can be used to establish
network provider agreements with I/T/Us as such agreements include the federal
protections for I/T/Us.
B. The MCO shall
allow native American members to seek care from any I/T/U whether
or not the I/T/U is a contract provider and shall reimburse I/T/Us as
specified in 8.308.20 NMAC. The MCO
shall permit non-contracted I/T/Us to refer native American members to a
contracted provider.
C. The MCO shall not
prevent members from seeking care from I/T/Us or from contract providers due to
their status as native Americans.
[8.308.2.15 NMAC -
N, 5/1/2018]
8.308.2.16 STANDARDS
FOR CREDENTIALING AND RE-CREDENTIALING: The
MCO shall verify that each contracted or subcontracted provider participating
in, or employed by the MCO meets applicable federal and state requirements for
licensing, certification, accreditation and re-credentialing for the type of
care or services within the scope of practice as defined by federal medicaid statues and state law. The MCO shall verify that billing providers,
rendering providers, ordering providers, attending providers, and prescribing
providers are enrolled with MAD, unless the services or providers are otherwise
exempted by MAD. The MCO shall document
the mechanism for credentialing and re-credentialing of a provider with whom it
contracts or employs to treat its members outside the inpatient setting and who
fall under its scope of authority. The
documentation shall include, but not be limited to, defining the provider’s
scope of practice, the criteria and the primary source verification of
information used to meet the criteria, the process used to make decisions, and
the extent of delegated credentialing or re-credentialing arrangements. The credentialing process shall be completed
within 45 calendar days from receipt of completed application with all required
documentation unless there are extenuating circumstances. The MCO shall use the HSD approved primary
source verification entity or one entity for the collection and storage of
provider credentialing application information unless there are more cost
effective alternatives approved by HSD.
The MCO must load provider contracts and claims systems must be able to
recognize the provider as a network provider no later than 45 calendar days
after a provider is credentialed, when required.
A. Practitioner
participation: The MCO shall have a
process for receiving input from participating providers regarding
credentialing and re-credentialing of its providers.
B. Primary source
verification: The MCO shall verify the
following information from primary sources during its credentialing process:
(1) a
current valid license to practice;
(2) the
status of clinical privileges at the institution designated by the practitioner
as the primary admitting facility, if applicable;
(3) valid
drug enforcement agency (DEA) or controlled substance registration (CSR)
certificate, if applicable;
(4) education
and training of practitioner including graduation from an accredited
professional program and the highest training program applicable to the
academic or professional degree, discipline and licensure of the practitioner;
(5) board
certification if the practitioner states on the application that he or she is
board certified in a specialty;
(6) current,
adequate malpractice insurance, according to the MCOs policy and history of
professional liability claims that resulted in settlement or judgment paid by
or on behalf of the practitioner; and
(7) primary
source verification shall not be required for work history.
C. Credentialing
application: The MCO shall use the HSD approved
credentialing form. The provider shall
complete a credentialing application that includes a statement by him or her
regarding:
(1) ability
to perform the essential functions of the positions, with or without
accommodation;
(2) lack
of present illegal drug use;
(3) history
of loss of license and felony convictions;
(4) history
of loss or limitation of privileges or disciplinary activity;
(5) sanctions,
suspensions or terminations imposed by medicare or medicaid; and
(6) applicant
attests to the correctness and completeness of the application.
D. External source
verification: Before a practitioner is
credentialed, the MCO shall receive information on the practitioner from the
following organizations and shall include the information in the credentialing
files:
(1) national
practitioner data bank, if applicable to the practitioner type;
(2) information
about sanctions or limitations on licensure from the following agencies, as
applicable:
(a) state
board of medical examiners, state osteopathic examining board, federation of
state medical boards or the department of professional regulations;
(b) state
board of chiropractic examiners or the federation of chiropractic licensing
boards;
(c) state
board of dental examiners;
(d) state
board of podiatric examiners;
(e) state
board of nursing;
(f) the
appropriate state licensing board for other practitioner types, including
behavioral health; and
(g) other
recognized monitoring organizations appropriate to the practitioner’s
discipline;
(3) a
health and human services (HHS) office of inspector general (OIG) exclusion
from participation on medicare, medicaid,
the children’s health insurance plan (CHIP), and all federal health care
programs (as defined in Section 1128B(f) of the Social Security Act), and
sanctions by medicare, medicaid,
CHIP or any federal health care program.
E. Evaluation of
practitioner site and medical records: The
MCO shall perform an initial visit to the offices of a potential PCP,
obstetrician, and gynecologist, and shall perform an initial visit to the
offices of a potential high volume behavioral health care practitioner prior to
acceptance and inclusion as a contracted provider. The MCO shall determine its method for
identifying high volume behavioral health practitioners.
(1) The
MCO shall document a structured review to evaluate the site against the MCO’s
organizational standards and those specified by the HSD managed care contract.
(2) The
MCO shall document an evaluation of the medical record keeping practices at
each site for conformity with the MCO’s organizational standards.
F. Re-credentialing:
The MCO shall have formalized re-credentialing procedures.
(1) The
MCO shall re-credential its providers at least every three years. The MCO shall verify the following
information from primary sources during re-credentialing:
(a) a
current valid license to practice;
(b) the
status of clinical privileges at the hospital designated by the practitioner as
the primary admitting facility;
(c) valid
DEA or CSR certificate, if applicable;
(d) board
certification, if the practitioner was due to be recertified or became board
certified since last credentialed or re-credentialed;
(e) history
of professional liability claims that resulted in settlement or judgment paid
by or on behalf of the practitioner; and
(f) a
current signed attestation statement by the applicant regarding:
(i) ability to perform the essential
functions of the position, with or without accommodation;
(ii) lack
of current illegal drug use;
(iii) history
of loss or limitation of privileges or disciplinary action; and
(iv) current
professional malpractice insurance coverage.
(2) There
shall be evidence that, before making a re-credentialing decision, the MCO has
received information about sanctions or limitations on licensure from the
following agencies, if applicable:
(a) the
national practitioner data bank;
(b) medicare and medicaid;
(c) state
board of medical examiners, state osteopathic examining board, federation of
state medical boards or the department of professional regulations;
(d) state
board of chiropractic examiners or the federation of chiropractic licensing
boards;
(e) state
board of dental examiners;
(f) state
board of podiatric examiners;
(g) state
board of nursing;
(h) the
appropriate state licensing board for other provider types;
(i) other recognized monitoring
organizations appropriate to the provider’s discipline; and
(j) HHS/OIG
exclusion from participation in medicare, medicaid, CHIP and all federal health care programs.
(3) The
MCO shall incorporate data from the following sources in its re-credentialing
decision making process for its providers:
(a) member
grievances and appeals;
(b) information
from quality management and improvement activities; and
(c) medical
record reviews conducted under Subsection E this Section.
G. Imposition of
remedies: The MCO shall have policies
and procedures for altering the conditions of the provider’s participation with
the MCO based on issues of quality of care and service. These policies and procedures shall define
the range of actions that the MCO may take to improve the provider’s
performance prior to termination:
(1) The
MCO shall have procedures for reporting to appropriate authorities, including HSD,
serious quality deficiencies that could result in a practitioner’s suspension
or termination.
(2) The
MCO shall have an appeal process by which the MCO may change the conditions of
a practitioner’s participation based on issues of quality of care and
service. The MCO shall inform providers
of the appeal process in writing.
H. Assessment of
organizational providers: The MCO shall
have written policies and procedures for the initial and ongoing assessment of
organizational providers with whom it intends to contract or which it is
contracted. At least every three years,
the MCO shall:
(1) confirm
that the provider has been certified by the appropriate state certification
agency, when applicable; behavioral health organizational providers and
services are certified by the following;
(a) the
department of health (DOH) is the certification agency for organizational
services and providers that require certification, except for child and
adolescent behavioral health services; and
(b) the
children, youth and families department (CYFD) is the
certification agency for child and adolescent behavioral health organizational
services and providers that require certification; and
(2) confirm
that the provider has been accredited by the appropriate accrediting body or
has a detailed written plan expected to lead to accreditation within a
reasonable period of time; behavioral health
organizational providers and services are accredited by the following:
(a) adult
behavioral health organizational services or providers are accredited by the
council on accreditation of rehabilitation facilities (CARF);
(b) child
and adolescent accredited residential treatment centers are accredited by the
joint commission (JC); other child behavioral health organizational services or
providers are accredited by the council on accreditation (COA); and
(c) organizational
services or providers who serve adults, children and adolescents are accredited
by either CARF or COA.
[8.308.2.16 NMAC -
Rp, 8.308.2.15 NMAC, 5/1/2018]
8.308.2.17 PROVIDER
TRANSITION: The MCO shall notify HSD within five calendar
days of unexpected changes to the composition of its provider network that
would have an effect on member access to services or
on the MCOs ability to deliver services included in the benefit package. Anticipated material changes in the MCO
provider network shall be reported in writing to HSD within 30 calendar days
prior to the change or as soon as the MCO becomes aware of the anticipated
change. For both expected and unexpected
changes in the network, the MCO shall be required to assess the significance of
the change or closure to the network and shall submit a notification narrative and
specific transition plans, if applicable, as detailed in the MCO policy manual.
[8.308.2.17 NMAC -
Rp, 8.308.2.16 NMAC, 5/1/2018]
8.308.2.18 DELEGATION: Delegation is a process whereby a MCO gives
another entity the authority and responsibilities to perform certain functions
on its behalf. The MCO is fully
accountable for all pre-delegation and delegation activities and decisions
made. The MCO shall document its oversight
of the entity that performs the delegated activity. The MCO may assign, transfer, or delegate to
a subcontractor key management functions with the explicit written approval of
HSD.
A. Each contract or
written agreement between the MCO and delegated entity shall describe:
(1) the
responsibilities of the MCO and the entity to which the activity is delegated;
(2) the
delegated activities or obligations;
(3) the
reporting responsibilities to include the frequency and method of reporting to
the MCO;
(4) the
process by which the MCO evaluates the delegated entity’s performance;
(5) the
remedies up to, and including, revocation of the delegation, available to the
MCO if the delegated entity does not fulfill its obligations; and
(6) the
requirements specified in 42 CFR § 438.214, if the delegated entity will be
providing or securing covered services to members.
B. The MCO shall provide
evidence to HSD that it:
(1) evaluated
the delegated entity’s capacity to perform the delegated activities prior to
delegation;
(2) monitors
the delegated entity’s performance on an ongoing basis and identifies
deficiencies or areas for improvement that require the delegated entity to take
corrective action as necessary; and
(3) conducts
an annual evaluation of its delegated entity in accordance with the MCO’s
expectations and HSD’s standards.
[8.308.2.18 NMAC -
Rp, 8.308.2.17 NMAC, 5/1/2018]
HISTORY OF 8.308.2 NMAC: [RESERVED]
History of
Repealed Material:
8.308.2 NMAC - Managed Care Program, Provider Network, filed
12/17/2013 Repealed effective 5/1/2018.