N.M. Stat. § 27-11-3 (2026)

organization; contract remedies; penalties.
    A. Consistent with the terms of any contract between the department and a
medicaid provider or managed care organization, the secretary shall have the right to be
afforded access to such of the medicaid provider's or managed care organization's
records and personnel, as well as its subcontracts and that subcontractor's records and
personnel, as may be necessary to ensure that the medicaid provider or managed care
organization is complying with the terms of its contract with the department.

   B. Upon not less than two days' written notice to a medicaid provider or managed
care organization, the secretary may, consistent with the provisions of the Medicaid
Provider and Managed Care Act and rules issued pursuant to that act, carry out an
administrative investigation or conduct administrative proceedings to determine whether
a medicaid provider or managed care organization has:

       (1)     materially breached its obligation to furnish medicaid-related services to
recipients, or any other duty specified in its contract with the department;

      (2)     violated any provision of the Public Assistance Act [27-2-1 to 27-2-34
NMSA 1978] or the Medicaid Provider and Managed Care Act or any rules issued
pursuant to those acts;

      (3)     intentionally or with reckless disregard made any false statement with
respect to any report or statement required by the Public Assistance Act or the Medicaid
Provider and Managed Care Act, rules issued pursuant to either of those acts or a
contract with the department;

      (4)    intentionally or with reckless disregard advertised or marketed, or
attempted to advertise or market, its services to recipients in a manner as to
misrepresent its services or capacity for services, or engaged in any deceptive,
misleading or unfair practice with respect to advertising or marketing;

      (5)    hindered or prevented the secretary from performing any duty imposed by
the Public Assistance Act, the Human Services Department [health care authority
department] Act [Heath Care Authority Act] [Chapter 9, Article 8 NMSA 1978] or the
Medicaid Provider and Managed Care Act or any rules issued pursuant to those acts; or

       (6)      fraudulently procured or attempted to procure any benefit from medicaid.

   C. Subject to the provisions of Subsection D of this section, after affording a
medicaid provider or managed care organization written notice of hearing not less than
ten days before the hearing date and an opportunity to be heard, and upon making
appropriate administrative findings, the secretary may take any or any combination of
the following actions against the medicaid provider or managed care organization:

       (1)    impose an administrative penalty of not more than five thousand dollars
($5,000) for engaging in any practice described in Subsection B of this section; provided
that each separate occurrence of such practice shall constitute a separate offense;

       (2)   issue an administrative order requiring the medicaid provider or managed
care organization to:

        (a) cease or modify any specified conduct or practices engaged in by it or its
employees, subcontractors or agents;

             (b) fulfill its contractual obligations in the manner specified in the order;
          (c) provide any service that has been denied;

          (d) take steps to provide or arrange for any service that it has agreed or is
otherwise obligated to make available; or

         (e) enter into and abide by the terms of a binding or nonbinding arbitration
proceeding, if agreed to by any opposing party, including the secretary; or

     (3)   suspend or revoke the contract between the medicaid provider or
managed care organization and the department pursuant to the terms of that contract.

    D. If a contract between the department and a medicaid provider or managed care
organization explicitly specifies a dispute resolution mechanism for use in resolving
disputes over performance of that contract, the dispute resolution mechanism specified
in the contract shall be used to resolve such disputes in lieu of the mechanism set forth
in Subsection C of this section.

    E. If a medicaid provider's or managed care organization's contract so specifies, the
medicaid provider or managed care organization shall have the right to seek de novo
review in district court of any decision by the secretary regarding a contractual dispute.

History: Laws 1998, ch. 30, § 3; 1999, ch. 229, § 1; 2019, ch. 215, § 3.

                                     ANNOTATIONS

Bracketed material. — The bracketed material was inserted by the compiler and is not
part of the law. Laws 2023, ch. 205, § 16 provided that references to the human
services department shall be deemed to be references to the health care authority
department.

Laws 2024, ch. 39, § 1, changed the name of the "Health Care Authority Department
Act" to the "Health Care Authority Act".

The 2019 amendment, effective January 1, 2020, added a "managed care
organization" as a medicaid provider; after "medicaid", deleted "providers" and added
"provider or managed care organization"; after each occurrence of "medicaid provider",
added "or managed care organization" throughout the section, and after each
occurrence of "Medicaid Provider", added "and Managed Care" throughout the section.

Severability. — Laws 2019, ch. 215, § 19, provided that if any part or application of this
act is held invalid, the remainder or its application to other situations or persons shall
not be affected.

The 1999 amendment, effective June 18, 1999, in Subsection B, deleted "Upon not
less than seven days' written notice to a medicaid provider" preceding "The secretary
may"; and in Subsection C(1), substituted "Paragraphs (1) through (6)" for "Paragraphs
(1) through (7)".