Non-Contracted Providers

The Federal No Surprises Act (NSA) requires the member’s cost-share to be based on the Qualifying Payment Amount (QPA) — also known as the median in-network rate. Providers cannot bill the member for more than their cost-share.

If you want to dispute payment for a claim that is subject to the NSA, you may initiate a 30-business-day open negotiation period. You have 30 business days from when you received the initial claim payment or denial to initiate an open negotiation period.

To initiate the open negotiation period, complete the Open Negotiation Notice and return:

• By mail:
  True Health New Mexico
  Attn: Provider Services
  P.O. Box 37200
  Albuquerque, NM 87176
• By email: provider.services@truehealthnewmexico.com.

Call Customer Service at 1-844-508-4677 for more information.

You may find the Open Negotiation Notice at https://www.dol.gov/sites/dolgov/files/ebsa/laws-and-regulations/laws/no-surprises-act/surprise-billing-part-ii-information-collection-documents-attachment-2.pdf.

If an agreement is not reached by the end of the open negotiation period, you may initiate the federal Independent Dispute Resolution (IDR) process for eligible claims within four business days of the end of the open negotiation period.

Initiating the federal IDR process does not prohibit us from agreeing on a payment amount after the open negotiation period has ended and before the certified IDR entity determines the payment amount.

For more information on the federal IDR process and to obtain the notice to initiate it, visit https://www.nsa-idr.cms.gov.

Email provider.services@truehealthnewmexico.com or call 1-844-508-4677 and ask for the Provider Contracting Department.

Non-contracted providers are required to obtain prior authorization for all services, except for services provided in an emergency department. Claims will be reviewed to determine member eligibility at the time of service, benefit availability, evidence of coverage provisions, and claims payment agreements.

Prior authorization is not a guarantee of payment.

Information Required to Request Prior Authorization

• Member’s name and subscriber number
• Scheduled date of procedure, transfer, admission, or service
• Name of attending, referring, or ordering physician
• Location of service and rendering physician
• Diagnosis
• Procedure
• Supporting clinical/medical information for request

How to Request Prior Authorization

• Prior authorization requests may be phoned in to True Health New Mexico Medical Management during normal business hours, Monday through Friday, 8:00 a.m.to 5:00 p.m. MST, or faxed to 1-866-628-3047.
• If providers require assistance for urgent (expedited) determinations after business hours, please call 1-844-508-4677 to reach an on-call nurse case manager.
• The Medical and Pharmacy Prior Authorization Request Form is on our Prior Authorization Requests page.

If a member is receiving an ongoing course of treatment from a non-participating provider when he or she enrolls in the Plan, the member may be eligible to continue to receive services and have them covered by the Plan. This is called a Transition of Care. Determinations for Transition of Care are made based on established medical criteria.

The Transition of Care Period will be for a period of no less than 30 days. Transition of Care also applies to members who have entered the third trimester of pregnancy, including post-partum care directly related to the delivery. The Transition of Care Request Form is on our Member Forms page.

Effective December 1, 2022, True Health New Mexico uses Availity for electronic data interchange (EDI) claim submissions.

Handwritten claims are NOT accepted.

All paper claims for individual, small group, and large group members must be submitted to:

True Health New Mexico
P.O. Box 211468
Eagan, MN 55121

All paper claims for Federal Employee Health Benefits members must be submitted to:

True Health New Mexico
P.O. Box 37200
Albuquerque, NM 87176

• Submit clean claims on a CMS-1500 form or a UB04 form, whichever is appropriate, that is compliant with the National Provider Identifier and Health Insurance Portability and Accountability Act regulations.
• Include valid CPT, Revenue, HCPCS, ASA and ICD-10 codes and modifiers where applicable.
• Ensure sure that all the fields are completed fully and accurately.
• Refer to the member’s current identification (ID) card to help ensure use of the appropriate member ID number and claims submission address/payor identification.
• Use machine/computer generated forms. True Health New Mexico does not accept handwritten claims. Additionally, claims with altered information or markings will not be accepted for consideration.
• Submit claims within 365 days from the date of service.

When submitting attachments or documents that are to be considered as part of the claim processing, you must include the member’s ID number on each page.

Where True Health New Mexico is the primary payer, True Health New Mexico will process clean claims received within 365 days from the date of service. If True Health New Mexico is the secondary payer, the clean claim will be processed within 365 days from the provider’s submission to True Health New Mexico of the receipt of a payment decision from the primary payor. Any claims submitted without the primary payor’s EOP will be denied with a request for the additional information.

True Health New Mexico is required to process clean claims upon receipt within 30 days for electronic submissions and 45 days for paper submissions. Providers will receive an Explanation of Payment (EOP) for all claims received. Claims may be rejected or be returned to the provider prior to acceptance into the claims system if any required information is missing.

Any claims submitted outside the timely filing requirements as noted above will not be considered for payment unless the provider has documented proof of timely follow-up at least monthly from the date claim was submitted to True Health New Mexico.

Providers can verify claim status with True Health New Mexico in the following ways:

• Complete and fax the Claims Inquiry Form on our Provider Forms page to (312) 548-9943.
• Call True Health New Mexico Customer Service to check the status of claims.
  • Call 1-844-508-4677 from 8:00 a.m. to 5:00 p.m. MST.
  • Calls are limited to five claims inquiries per call.

If you need assistance with overpayment inquiries, call Customer Service at 1-844-508-4677, Monday through Friday from 8:00 a.m. to 5:00 p.m. Or complete the Physician and Facility Claims Refund Form on our Provider Forms page.

When an overpayment is identified by the provider, the provider should send the Physician and Facility Claims Refund Form with supporting documentation and the refund check to:

True Health New Mexico
Attention: Finance
P.O. Box 37200
Albuquerque, NM 87176

Supporting documentation should include:

• Member name and ID number
• Provider Tax Identification Number
• Date of service
• Amount of overpayment
• True Health New Mexico’s payment date
• Detailed reason for the refund

True Health New Mexico reserves the right to request clinical records before or after claim payment in order to identify possible fraud, waste, and/or abusive billing practices, as well as any other inappropriate billing practice not consistent or compliant with the guidelines listed above.

True Health New Mexico conducts subrogation investigations for services that may indicate third-party liability. When the member or provider receives money to compensate for medical or hospital care for injuries or illness caused by another party, True Health New Mexico must be reimbursed for any expenses that may have paid in connection to the incident. If the member or provider does not seek damages, the provider must agree to allow True Health New Mexico to attempt recovery. For more information regarding subrogation policies and procedures, please call Customer Service at 1-844-508-4677.

If True Health New Mexico does not pay clean claims in accordance with the time frames specified in the applicable law, True Health New Mexico shall be liable for the amount due and unpaid with interest on that amount at the rate specified by the New Mexico Office of Superintendent of Insurance.

In the event that True Health New Mexico determines that a claim is not a clean claim, True Health New Mexico will advise the provider of the basis upon which the claim is not a clean claim and specify any additional information required.

• Electronic claim adjustments: Service Loop CLM 05/03 Frequency Field “7” (I – Institutional OR P – Professional) – this indicator will allow for an electronic claim adjustment.
• Paper claim adjustments: Providers must file CMS-1450 or CMS-1500 paper forms, including any required and supporting documentation such as the EOB, original paper claim form and clinical documentation. Mail the paper claim adjustment to:

True Health New Mexico
P.O. Box 211468
Eagan, MN 55121

Appeals are defined as a dispute regarding the denial of payment for a claim, in whole or in part.

When submitting appeals challenging the denial of a claim in whole or part, non-contracted providers must file an appeal request within 365 days from the date of the initial Explanation of Payment (EOP). Appeals must be submitted in writing following claims processing and receipt of a formal, written denial from True Health New Mexico. True Health New Mexico allows non-contracted providers one level of appeal review.

Requests for appeal are reviewed and a determination is generally made within 60 days from the date of receipt of the appeal by True Health New Mexico.

The Provider Payment Appeal Request Form is on our Provider Forms page.

Providers may file a written appeal by fax or in writing:

• By fax: 1-800-747-9132, Attention: Appeals and Grievances
• In writing:

True Health New Mexico
Attention: Appeals
P.O. Box 37200
Albuquerque, NM 87176-9907

Please review the Reassessments/Adjustment Requests section of the Claims Submission and Payment section to determine if non-payment requires a reassessment or adjustment request or filing a formal, written appeal. Claim reassessment/adjustment requests submitted as appeals will be returned to the provider to submit via the appropriate claim reassessment/adjustment process.

Payment disputes are defined as a dispute claiming that payment was not made at the pre-negotiated rate. The dispute will result in a request from the provider to re-assess the claim payment amount.

Providers are responsible to immediately post and track all claim payments and/or denials based on the EOP provided by True Health New Mexico.

If you want to dispute payment for a claim that is subject to the Federal No Surprises Act, you may contact True Health New Mexico Customer Service at 1-844-508-4677 or provider.services@truehealthnewmexico.com to initiate a 30-business-day open negotiation period for purposes of determining the out-of-network rate.

If the 30-business-day open negotiation period does not result in an agreement on the out-of-network rate, you may initiate the Federal IDR process within four days of the end of the open negotiation period.

Re-Assessment/Re-Adjustment Requirements

• The request must be made in writing within 365 days of the claim payment date.
• Make the request via True Health New Mexico by calling Customer Service at 1-844-508-4677, Monday through Friday from 8:00 a.m. to 5:00 p.m., OR
• Complete the Claim Readjustment/Re-Assessment Request Form on our Provider Forms page and either mail or fax the form to the address/fax number on the form.