NMHC is dedicated to providing our members with access to effective, high-quality, affordable health care. In order to ensure we maintain the highest integrity throughout our provider network, we verify and review the credentials of our participating practitioners and facilities initially, and again every three years. This process helps us maintain and improve the quality of care and services delivered to our members.
NMHC’s credentialing processes and standards have been designed to be consistent with broadly adopted standards, including NCQA and New Mexico statutory and regulatory requirements.
NMHC prefers that physicians wishing to participate in the NMHC network are board-certified or board-eligible in their area of specialty; however, all practitioners applying for participation in the NMHC network must meet, at a minimum, the following NMHC eligibility criteria for initial credentialing and for re-credentialing:
- Current, valid, and unrestricted license to practice in the state in which the practitioner will treat NMHC members.
- For prescribing practitioners: Current and unrestricted Drug Enforcement Administration (DEA) registration and current unrestricted state Controlled Dangerous Substance (CDS) certificate, if applicable, in the state in which the practitioner practices. If a prescribing practitioner does not prescribe medications, he or she must submit a written description of a formal arrangement for medication prescription for his or her patients should any of them require medication.
- Graduation from medical school or professional school.
- For physicians: Completion of residency program approved by the Accreditation Council for Graduate Medical Education (ACGME).
- For non-physicians: Completion of master’s degree and state mandated clinical hours, and certification, if appropriate.
- Current professional liability (malpractice) insurance.
- For physicians and other practitioners with hospital privileges: Clinical privileges in good standing at the facility designated by the practitioner as the primary admitting facility. If a practitioner does not have admitting privileges, he or she must submit a written description of a formal arrangement for inpatient coverage for his or her patients should any of them require hospitalization.
NMHC prefers the CAQH Universal Provider DataSource (UPD) application for gathering data about practitioners initially, and then every three years thereafter for re-credentialing. Practitioners are encouraged to update their online CAQH applications prior to credentialing or re-credentialing with NMHC.
Providers who have not completed the credentialing process and have not been approved by the NMHC Credentialing Committee are considered Non-Contracted or “out of network” with NMHC. Claims for services rendered by Non-Credentialed, Non-Contracted providers may be denied payment.
Practitioners must have in their possession a signed agreement and the credentialing approval letter to begin to treat NMHC members.
Practitioner Rights Related to the Credentialing Process
Physicians and other health care practitioners applying for participation in the NMHC provider network have the following rights regarding the credentialing process:
- The right to review the information submitted to support the credentialing application;
- The right to correct erroneous information; and
- The right to be informed of the status of the credentialing or re-credentialing application, upon request.