This text of New Mexico § 13-7-45 (Dental coverage; provider network leasing) is published on Counsel Stack Legal Research, covering New Mexico primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.
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 t
Free access — add to your briefcase to read the full text and ask questions with AI
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.