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Health Care Providers

NMSA 1978 ch. 52, art. 4
in effect

NMSA 1978, § 52-4-1 Definition; health care provider

52-4-1. Definition; health care provider As used in Chapter 52 NMSA 1978, "health care provider" means: A. a hospital maintained by the state or a political subdivision of the state or any place currently licensed as a hospital by the department of health that has: (1) accommodations for resident bed patients; (2) a licensed professional registered nurse always on duty or call; (3) a laboratory; and (4) an operating room where surgical operations are performed; B. an optometrist licensed pursuant to the provisions of Chapter 61, Article 2 NMSA 1978; C. a chiropractic physician licensed pursuant to the provisions of Chapter 61, Article 4 NMSA 1978; D. a dentist licensed pursuant to the provisions of Chapter 61, Article 5 NMSA 1978; E. a physician licensed pursuant to the provisions of Chapter 61, Article 6 NMSA 1978; F. a podiatrist licensed pursuant to the provisions of Chapter 61, Article 8 NMSA 1978; G. an osteopathic physician licensed pursuant to the provisions of Chapter 61, Article 10 NMSA 1978; H. a physician assistant licensed pursuant to the provisions of Section 61-6-7 NMSA 1978; I. a certified nurse practitioner licensed pursuant to Section 61-3-23.2 NMSA 1978; J. a physical therapist licensed pursuant to the provisions of Chapter 61, Article 12 NMSA 1978; K. an occupational therapist licensed pursuant to the provisions of Chapter 61, Article 12A NMSA 1978; L. a doctor of oriental medicine licensed pursuant to the provisions of Chapter 61, Article 14A NMSA 1978; M. an athletic trainer licensed pursuant to the provisions of Chapter 61, Article 14D NMSA 1978; N. a psychologist who is duly licensed or certified in the state where the service is rendered, holding a doctorate degree in psychology and having at least two years of clinical experience in a recognized health setting, or who has met the standards of the national register of health services providers in psychology; O. a certified nurse-midwife licensed by the board of nursing as a registered nurse and registered with the behavioral health services division of the human services department [health care authority department] as a certified nurse-midwife; P. a pharmacist licensed pursuant to the provisions of Chapter 61, Article 11 NMSA 1978; or Q. any person or facility that provides health-related services in the health care industry, as approved by the director. 1978 Comp., § 52-4-1, enacted by Laws 1983, ch. 116, § 1; 1989, ch. 263, § 69; 1990 (2nd S.S.), ch. 2, § 49; 1993, ch. 158, § 2; 2007, ch. 325, § 11; 2007, ch. 327, § 1; 2007, ch. 328, § 3.

NMSA 1978, § 52-4-2 Utilization review; penalties

52-4-2. Utilization review; penalties A. The director shall establish a system of peer group utilization review of selected outpatient and inpatient health care provider services to workers claiming benefits under the Workers' Compensation Act [Chapter 52, Article 1 NMSA 1978] or the New Mexico Occupational Disease Disablement Law [52-3-1 NMSA 1978]. Subject to the provisions of this section, the decisions issued pursuant to the utilization review system shall be binding on the affected health care providers, workers, employers, insurers and their representatives. B. As used in this section, "utilization review" means an evaluation of the necessity, appropriateness, efficiency and quality of health care services provided to an injured or disabled worker based on medically accepted standards and an objective evaluation of the health care services provided. C. The director shall also establish a system of pre-admission review of all hospital admissions, except for emergency services. Utilization review shall commence within one working day of all emergency hospital admissions. D. The director may contract with an independent utilization review organization to provide utilization review, including peer review. E. Nothing in this section shall prevent an employer from electing to provide his own utilization review; however, if the worker, provider or any other party not contractually bound to the employer's utilization review program disagrees with that employer's utilization review, then that worker, provider or other party shall have recourse to the workers' compensation administration's utilization review program. F. Pursuant to utilization review conducted by the director, including providing an opportunity for a hearing, any health care provider who imposes excessive charges or renders inappropriate services shall be subject to: (1) a forfeiture of the right to payment for those services that are found to be excessive or inappropriate or payment of excessive charges; (2) a fine of not less than one hundred dollars ($100) or more than one thousand dollars ($1,000); or (3) a temporary or permanent suspension of the right to provide health care services for workers' compensation or occupational disease disablement claims if the health care provider has established a pattern of violations. 1978 Comp., § 52-4-2, enacted by Laws 1990 (2nd S.S.), ch. 2, § 50; 1993, ch. 193, § 8.

NMSA 1978, § 52-4-3 Case management

52-4-3. Case management A. The director shall establish a system of case management for coordinating the health care services provided to workers claiming benefits under the Workers' Compensation Act [Chapter 52, Article 1 NMSA 1978] or the New Mexico Occupational Disease Disablement Law [52-3-1 NMSA 1978]. B. As used in this section, "case management" means the ongoing coordination of health care services provided to an injured or disabled worker, including but not limited to: (1) developing a treatment plan to provide appropriate health care services to an injured or disabled worker; (2) systematically monitoring the treatment rendered and the medical progress of the injured or disabled worker; (3) assessing whether alternate health care services are appropriate and delivered in a cost-effective manner based on acceptable medical standards; (4) ensuring that the injured or disabled worker is following the prescribed health care plan; and (5) formulating a plan for return to work. C. The director shall contract with an independent organization to assist with the administration of the provisions of this section. D. Nothing in this section shall prevent an employer from establishing his own program of case management; however, for the purposes of resolving choice of health care provider disputes, an employer or worker shall only use the program as provided by the workers' compensation administration, as set forth in Section 52-1-49 NMSA 1978. 1978 Comp., § 52-4-3, enacted by Laws 1990 (2nd S.S.), ch. 2, § 51.

NMSA 1978, § 52-4-4 Temporary provision; rules and regulations

52-4-4. Temporary provision; rules and regulations A. The director shall adopt and promulgate regulations and contract with a peer review organization pursuant to Section 52-4-2 NMSA 1978 no later than October 1, 1990. B. The director shall establish a baseline period of no less than six months, adjusted for seasonal variations, for the purpose of providing data for the calculations required pursuant to Subsection C of this section no later than January 1, 1991. C. For the one-year period ending December 31, 1991, the director shall issue a report concerning the results of the utilization review program as provided in Section 52-4-3 NMSA 1978 no later than December 1, 1992. If the director determines that based on such data the program has not resulted in a ten percent reduction in the utilization and cost of services subject to the utilization program, he shall have the authority to adopt and promulgate regulations, after notice and public hearings, to establish schedules of maximum charges for fees that are payable to health care providers as defined in Section 52-4-1 NMSA 1978. Such schedules shall be annually revised. D. For the purposes of calculating the percentage as provided in Subsection C of this section, a comparison of both baseline and utilization program data shall be performed. Factors that shall be considered include, but are not limited to: (1) severity and frequency of illness or injury; (2) average length of stay of hospitalization; (3) number of admissions per one hundred workers' compensation claims; (4) number of services provided per one hundred workers' compensation claims; and (5) factors that may affect the utilization and cost of medical services provided under the Workers' Compensation Act [Chapter 52, Article 1 NMSA 1978]. Laws 1990, ch. 65, § 4.

NMSA 1978, § 52-4-5 Fee schedule

52-4-5. Fee schedule A. The director shall adopt and promulgate regulations establishing a schedule of maximum charges as deemed necessary for treatment or attendance, service, devices, apparatus or medicine provided by a health care provider. The rates in the schedules of maximum charges shall not fall below the sixtieth percentile or above the eightieth percentile of current rates for health care providers. In determining current rates for health care providers, the director shall utilize a variety of health care provider charges, including the charges of those providers serving low income, medicare and medicaid patients. B. A health care provider shall be paid his usual and customary fee for services rendered or the maximum charge established pursuant to Subsection A of this section, whichever is less. However, in no case shall the usual and customary fee exceed the maximum charge allowable. C. The fee schedule shall be revised annually by the director. D. No amount in excess of the amount required by Subsection B of this section for a service shall be paid by the employer, the employer's insurer, the worker, a representative of the worker or any other person to a health care provider for rendering that service in connection with an injury or disablement within the purview of the Workers' Compensation Act [Chapter 52, Article 1 NMSA 1978] or the New Mexico Occupational Disease Disablement Law [52-3-1 NMSA 1978]. E. If it is determined by the person primarily responsible for payment that the charges of a health care provider exceed the amount established pursuant to Subsection B of this section or that a health care provider over-utilized or otherwise rendered or ordered inappropriate health care or health care services, and payment is withheld on those grounds, the health care provider may appeal to the director regarding that determination. The director shall establish by regulation procedures for an appeal by a health care provider. F. The director shall establish an advisory committee that shall: (1) be appointed and serve at the pleasure of the director; (2) consist of members, a majority of whom represent health care providers; (3) reflect the diversity of authorized licensed health care providers available for workers' compensation and occupational disease disablement cases; (4) assist in establishing the schedules of maximum charges under Subsection A of this section for any fees that are payable to health care providers; (5) assist the director in adopting regulations for employers' utilization review procedures and the establishment and conduct of utilization review boards; and (6) report its findings, upon request, to the director and the advisory council on workers' compensation. G. The schedule of maximum charges specified in this section shall not apply to hospital charges. The director shall establish a separate schedule of maximum charges for hospital charges no later than April 1, 1991. H. Nothing in this section shall prevent an employer from contracting with a health care provider for fees less than the maximum charges allowable. 1978 Comp., § 52-4-5, enacted by Laws 1990 (2nd S.S.), ch. 2, § 52; 1993, ch. 193, § 9.
Source: New Mexico Compilation Commission (nmonesource.com)URL: https://nmonesource.com/nmos/nmsa-unanno/en/item/18555/index.doFetched: 10/20/2026

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