New Mexico Administrative Code

The purpose of this rule is to provide a method for enforcement by the WCA of the prohibition against bad faith, unfair claims processing, fraud, and of any other obligation of a party or agent of a party under the act and the WCA rules and regulations.

A. "Enforcement Bureau" means the division of the WCA charged with investigating and prosecuting violations of the act or WCA rules. B. See also 11.4.1.7 NMAC.

A. Any person may bring an allegation of prohibited conduct under the act, including criminal fraud, bad faith, unfair claims processing, retaliation, or non-compliance with the requirements of the act, to the attention of the WCA's enforcement bureau. B. Any party may initiate a…

A. The enforcement bureau may serve a notice of pending investigation to appropriate persons or entities by hand delivery or certified mail, domestic return receipt requested, or by electronic mail for those parties registered with the WCA. B. The notice of pending investigation …

Workers' Compensation Administration.

All appointments and reappointments of judges.

Section 52-5-2 NMSA 1978 (Repl. Pamp. 1991).

Permanent.

December 31, 2013, unless a later date is cited at the end of a section.

The purpose of this rule is to provide a mechanism for selection of Judges that allows for public notice of vacancies, public comment on reappointment of judges and public inspection of judicial applications.

See 11 NMAC 4.1.7.

A. The director may review the performance of workers' compensation judges at least once each year in a manner determined by the director. B. The director shall announce the expiration of the term of a current workers' compensation judge not later than 120 days prior to the expir…

Workers' Compensation Administration (WCA).

A. An HCP that is not licensed in the state of New Mexico must be approved by the director to qualify as an HCP under the act. B. No party shall have recourse to the billing and payment dispute resolution provisions of these rules with respect to the services of an HCP who is not…

A. In the event of a billing or payment dispute any party may submit to the medical cost containment bureau a request for director's determination on the approved form located on the WCA website. B. The request shall be made in writing within 30 days of the documented receipt dat…

A. Basic provisions. (1) All workers and their legal representatives are required to cooperate with the WCA or its contractor, if any, with respect to all reasonable requests for information necessary for any provision of service. (2) For the purpose of facilitating the provision…

A. For medical records and report copies requested for the purpose of investigating or administering a workers' compensation claim, a practitioner may charge for paper and electronic copies as set forth in the HCP fee schedule, except as provided in Paragraphs (12), (13), (14) an…

Any complaint of a violation of these rules shall be made, in writing, to the medical cost containment bureau, enforcement bureau, or assigned workers' compensation judge, if any.

A. The insurer must report an inpatient hospital bill to the WCA within 10 to 90 days of payment of the bill. Reports may be submitted by mail, fax, or electronic media in batches daily, weekly, or monthly from the insurer or insurer's representative. B. The paid inpatient servic…

The agency website shall contain educational Return-To-Work best practice tools and resources for workers' compensation stakeholders.

This rule applies to workers, employers, and insurers and to all workers' compensation health care services providers, caregivers, pharmacies, and suppliers and all payers for such services and supplies.

Sections, 52-4-2, 52-4-3, 52-4-5, 52-5-4, and NMSA 1978.

Permanent.

January 1, 2023, unless a later date is cited at the end of a section.

The purpose of these rules is to establish and enforce a system of maximum allowable fees and reimbursements for health care services and related non-clinical services provided by all practitioners, to establish billing dispute procedures and to establish the procedures for cost …

The definitions in 11.4.1.7 NMAC shall apply to this rule. In addition, the following definitions apply to the provision of all services. A. "Business day" means any day on which the WCA is open for business. B. "By-Report (BR)" means a maximum amount for a service has not been e…

A. Basic ground rules. (1) These rules apply to all charges and payments for medical, other health care treatment, and related non-clinical services covered by the New Mexico Workers' Compensation Act and the New Mexico Occupational Disease Disablement Law. (2) These rules shall …

A. HCP fee schedule.(1) The director shall issue an order pursuant to Section 52-4-5 NMSA 1978 not less than once per annum setting the HCP fee schedule which shall list the maximum amount of reimbursement for, or the method for determining the maximum amount of reimbursement for…

Workers' Compensation Administration.

This rule applies to all corporations, companies or other entities applying for self-insurance, those who are or were certified for self-insurance, and to their agents and representatives.

Chapter 52 NMSA 1978.

Permanent.

October 1, 2015, unless a later date is cited at the end of a section.

The purpose of these rules is establish the minimum qualification criteria for a private company or qualifying public entity to apply to the director for permission to self-insure their workers' compensation risk and to establish the criteria to maintain such self-insured status …

A. "Approved excess insurer" means an insurer domiciled within the United States of America or an alien insurer listed in the national association of insurance commissioner's (NAIC) quarterly listing of alien insurers with a rating of "A" or better by A.M. Best or similar rating …

A. An employer seeking to be certified as a self-insurer under the Act shall make application on a form prescribed by the director. B. The director shall notify the chairman of the guarantee board of the identity of any applicant for self-insurance within 15 days of the receipt o…

A. Commission membership is composed of all self-insurers as defined in Section 52-8-3(J) NMSA 1978, as a condition of their authority to individually self-insure in the state of New Mexico. B. Withdrawal of membership: (1) A member shall be automatically withdrawn from the commi…

Workers' Compensation Administration.

These rules apply to the application, qualification, evaluation and regulatory requirements pertaining to group self-insureds authorized pursuant to NMSA 1978, Chapter 52, Article 6.

The authority for this part derives from the director's powers under NMSA 1978, Sections 52-6-1 through 52-6-25 and 52-1-4 A.

Permanent.

August 1, 1996, unless a later date is cited at the end of a section.

The purpose of these rules is to provide criteria and procedures to apply to the issuance and maintenance of certificates of self-insurance to group employers under the group Self-Insurance Act, NMSA 1978, Chapter 52, Article 6.

The definitions adopted below shall apply to all WCA rules, especially those for group self insurance. A. "Same or similar type of business" means that each individual business to be insured by a group at the time the risk is bound, without regard to ownership, is appropriate und…

A. Application and maintenance: (1) All the requirements for application and maintenance of a certificate of group self-insurance are contained in NMSA 1978, Section 52-6-5. In addition, the following shall apply: (a) Submit with the application a non-refundable fling fee of five…

Environmental Improvement Board.

Future amendments: No future amendment to 11.5.1 NMAC through 11.5.4 NMAC or 11.5.6 NMAC shall affect any administrative or judicial enforcement action pending on the effective date of the amendment.

The provisions of 11.5.1 NMAC through 11.5.4 NMAC and 11.5.6 NMAC shall be liberally construed to effectuate the purpose of the state act.

Compliance with the provisions of 11.5.1 NMAC through 11.5.4 NMAC and 11.5.6 NMAC does not relieve a person from the obligation to comply with other applicable state and federal regulations.

An employer who is in compliance with the provisions of 11.5.1 NMAC through 11.5.4 NMAC and 11.5.6 NMAC, including any incorporated federal standards, shall be deemed in compliance with the requirement of Subsection A of Section 50-9-5 NMSA 1978, but only to the extent of the con…