New Mexico § 13-7-43 - Dental coverage; erroneously paid claims; restrictions on recovery

§ 13-7-43. Dental coverage; erroneously paid claims; restrictions on recovery

A. Group coverage, including any form of self-insurance, offered, issued or renewed

under the Health Care Purchasing Act that offers a dental plan shall establish policies

and procedures for payment recovery, including providing: (1) notice to the provider that identifies the error made in the processing or payment

of the claim; (2) an explanation of the recovery being sought; and (3) an opportunity for the provider to appeal the recovery being sought as set forth

in Subsection C of this section. B. Group coverage, including any form of self-insurance, offered, issued or renewed

under the Health Care Purchasing Act that offers a dental plan shall not initiate

payment recovery procedures more than twenty-four months after the original payment

for a claim was made unless the claim was fraudulent or intentionally misrepresented. C. Group coverage, including any form of self-insurance, offered, issued or renewed

under the Health Care Purchasing Act that offers a dental plan shall not attempt to

recover an erroneously paid claim by withholding or reducing payment for a different

claim unless the plan: (1) notifies the provider, in writing, within twelve months of the erroneously paid

claim; and (2) advises the provider that an automatic deduction shall occur within forty-five

days of receiving notification unless the provider submits a written appeal to the

plan pursuant to the grievance rules prescribed by the superintendent of insurance. D. The provisions of this section shall not apply to duplicate payments.