HEALTH INSURANCE CREDENTIALING

HB0136

HOUSE BILL 136

57th legislature - STATE OF NEW MEXICO - second session, 2026

INTRODUCED BY

Kathleen Cates
and
Elizabeth "Liz" Thomson

and
Elizabeth "Liz" Stefanics

AN ACT

RELATING TO INSURANCE; REQUIRING THE HEALTH CARE AUTHORITY TO
ESTABLISH A CENTRALIZED CREDENTIALING APPLICATION PROCESS,
INCLUDING A TIME FRAME FOR MEDICAID MANAGED CARE PROVIDERS TO
LOAD INFORMATION ON CREDENTIALED PROVIDERS INTO THEIR PROVIDER
PAYMENT SYSTEMS.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:

SECTION 1.
Section 27-2-12.12 NMSA 1978 (being Laws 2003,
Chapter 235, Section 4) is amended to read:

"27-2-12.12. [
HUMAN SERVICES DEPARTMENT
]
HEALTH CARE
AUTHORITY
--[
MANAGED CARE CONTRACT
] CREDENTIALING PROVISIONS.--

A. No later than January 1, 2027
, the [
human
services department
]
authority
shall [
negotiate with medicaid
contractors to ensure that the contractors' credentialing
requirements are coordinated with other credentialing processes
required of
]
establish a centralized credentialing application
process for
individual providers.
Under the centralized
credentialing application process, individual providers shall
only be required to submit a credentialing application to the
authority. Each medicaid managed care contractor shall rely
upon the application submitted to the authority to make
credentialing decisions.

B. When an individual provider submits a
credentialing application to the authority, a medicaid managed
care contractor or a medicaid managed care contractor's agent
shall:

(1) assess and verify the qualifications of a
provider 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 of a felony conviction, a revocation of
clinical privileges or a denial of insurance coverage, requires
additional consideration;

(3) within ten calendar 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 medicaid
managed care contractor 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,
physical address, email 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 calendar days as described in Paragraph (2) of this
subsection, load into the medicaid managed care contractor's
provider payment system all provider information, including all
information needed to correctly reimburse a newly approved
provider according to the provider's contract. The medicaid
managed care contractor or medicaid managed care contractor's
agent shall add the approved provider's data to the provider
directory upon loading the provider's information into the
medicaid managed care contractor's provider payment system.

C. After a provider is initially credentialed by a
medicaid managed care contractor, the medicaid managed care
contractor shall not require subsequent credentialing more than
once every three years.

D. The secretary shall promulgate rules to
implement the provisions of this section.

E. Nothing in this section shall be construed to
require a medicaid managed care contractor to credential a
provider who does not meet the medicaid managed care
organization's requirements to participate in the medicaid
managed care organization's plan.

F. As used in this section:

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

(2) "provider" means a physician or other
individual licensed or otherwise authorized to furnish health
care services in the state.
"

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