New Mexico § 13-7-45 - Dental coverage; provider network leasing

§ 13-7-45. Dental coverage; provider network leasing

A. For purposes of this section: (1) “ contracting entity ” means any person or entity that enters into direct contracts with a provider for

the delivery of services in the ordinary course of business; (2) “ provider ” means a person acting within the scope of licensure to provide dental services or

supplies; (3) “ provider network contract ” means a contract between a contracting entity and a provider specifying the rights

and responsibilities of the contracting entity and providing for the delivery of and

payment for services to the insured; and (4) “ third party ” means a person or entity that enters into a contract with a contracting entity or

with another third party to gain access to the services or contractual discounts of

a provider network contract. B. At a time when a contract relevant to granting access to a provider network to

a third party is entered into or renewed, or when there are material modifications

made, a contracting entity shall not require a provider to participate in third-party

access to the provider network contract or contract directly with a third party that

acquired the provider network. If a provider opts out, the contracting entity shall not cancel or otherwise end

a contractual relationship with the provider. When initially contracting with a provider, a contracting entity must accept a qualified

provider even if the provider rejects a network lease provision. C. A contracting entity shall not grant a third party access to a provider network

contract, a provider's services or discounts provided pursuant to a provider network

contract unless: (1) the provider network contract states that the contracting entity may enter into

an agreement with a third party, allowing the third party to obtain the insurer's

rights and responsibilities as though the third party were the contracting entity; (2) the third party accessing the provider network contract agrees to comply with

all of the terms of the provider network contract; and (3) the contracting entity: (a) identifies all third parties with which it contracts in a list on its website

that is updated every ninety days; (b) notifies a provider that a new third party is planning to lease or purchase the

provider network contract, at least thirty business days before the lease or purchase

takes effect; (c) requires the third party to identify the source of the discount on all remittances

or explanation of benefits under which the discount is taken; and (d) makes available a copy of the provider network contract relied upon in the adjudication

of a claim to a provider within thirty days of the provider's request. D. A third party's right to a provider's discounted rate shall cease upon the termination

date of the provider network contract. E. The provisions of this section shall not apply if access to a provider network

contract is granted to a dental carrier of an entity operating in accordance with

the same brand licensee program as the contracting entity or to an entity that is

an affiliate of the contracting entity. A list of the contracting entity's affiliates shall be made available to a provider

on the contracting entity's website.