TITLE 8 SOCIAL SERVICES
CHAPTER 308 MANAGED CARE PROGRAM
PART 15 GRIEVANCES AND APPEALS
8.308.15.1 ISSUING AGENCY: New Mexico Human Services Department (HSD).
[8.308.15.1
NMAC - Rp, 8.308.15.1 NMAC, 5/1/2018]
8.308.15.2 SCOPE: This rule applies to the general public.
[8.308.15.2 NMAC - Rp, 8.308.15.2 NMAC, 5/1/2018]
8.308.15.3 STATUTORY AUTHORITY: The New Mexico medicaid program and other
health care programs are administered pursuant to regulations promulgated by
the federal department of health and human services under Title XIX of the
Social Security Act as amended or by state statute. See Sections 27-2-12 et seq., NMSA 1978.
[8.308.15.3
NMAC - Rp, 8.308.15.3 NMAC, 5/1/2018]
8.308.15.4 DURATION: Permanent.
[8.308.15.4
NMAC - Rp, 8.308.15.4 NMAC, 5/1/2018]
8.308.15.5 EFFECTIVE DATE: May 1, 2018 unless a later date is cited at
the end of a section.
[8.308.15.5
NMAC - Rp, 8.308.15.5 NMAC, 5/1/2018]
8.308.15.6 OBJECTIVE: The objective of this rule is to provide
instructions for the service portion of the New Mexico medical assistance
division programs.
[8.308.15.6
NMAC - Rp, 8.308.15.6 NMAC, 5/1/2018]
8.308.15.7 DEFINITIONS:
A. “Administrative law judge (ALJ)” means the
hearing officer appointed by the HSD fair hearings bureau (FHB) to oversee the
claimant’s administrative hearing process, to produce an evidentiary record and
render a recommendation to the medical assistance division (MAD) director.
B. “Adverse action against a member” is when a HSD managed care
organization (MCO) intends or has taken action against a member of his or her
MCO as in one or more of the following situations.
(1) An adverse
benefit determination is the denial, reduction, limited authorization,
suspension, or termination of a newly requested benefit or benefit currently
being provided to a member including determinations based on the type or level
of service, medical necessity criteria or requirements, appropriateness of
setting, or effectiveness of a service other than a value-added service. It includes the following:
(a) a change to a
level of care (LOC) benefit currently being received through a MCO, including a
reduction or other change in the member’s LOC, and a transfer or discharge of a
nursing facility (NF) resident;
(b) the
retrospective denial, reduction, or limited authorization of a benefit rendered
which was provided on a presumed emergency basis, whether in or out of network,
or provided without having received any required authorization or LOC
determination prior to the service being rendered, with the exception of a MCO
value-added service;
(c) the denial in whole or in part of a member’s provider claim
by the MCO regardless of whether the member is being held responsible for
payment;
(d) the failure of the MCO, or its designee:
(i) to make a benefit determination in a timely manner;
(ii) to provide a benefit in a timely matter;
(iii) to act within the timeframes regarding the MCO’s established
member appeal requirements;
(e) the
belief of a member, his or her authorized representative or authorized provider
that the MCO’s admission determination, LOC determination, or preadmission
screening and annual resident review (PASRR) requirements determination is not accurate
or the belief that the frequency, intensity or duration of the benefit is
insufficient to meet the medical needs of the member. When the issue stems from a PASRR
determination, the member will request a HSD PASRR administrative hearing
governed by 8.354.2 NMAC instead of a MCO member appeal or a HSD administrative
hearing; and
(f) the denial of a request to dispute a financial liability,
including co-payments, premiums or other member financial liabilities.
(2) Other actions
include:
(a) a
budget or allocation for which a member, his or her authorized representative,
or authorized provider believes the member’s home and community-based waiver
benefit or the member’s budget or allocations were erroneously determined or is
insufficient to meet the member’s needs; and
(b) a denial, limitation, or non-payment of emergency or
non-emergency transportation, or meals and lodging.
C. “Adverse action against a provider”
means when a MCO intends or has taken adverse action against a provider based
on the MCO
denial of the provider’s payment, including a denial of a claim for lack of
medical necessity or as not a covered benefit.
D. “Authorized provider” means the member’s
provider who has been authorized in writing by the member or his or her
authorized representative to request a MCO expedited member appeal or a MCO
standard member appeal on behalf of the member.
An authorized provider does not have the full range of authority to make
medical decisions on behalf of the member.
E. “Authorized
representative” means the individual designated by the member or legal
guardian to represent and act on the member’s behalf.
(1) The
member or authorized representative must provide documentation authorizing the
named individual or individuals to access the identified case information for a
specified purpose and time-frame. An
authorized representative may be an attorney representing a person or
household, a person acting under the authority of a valid power of attorney, a
guardian, or any other individual or individuals designated in writing by the
member.
(2) If a member, due to his or her
medical incapacity, is unable to appoint an authorized representative and the
authorized representative is unable to be reached and immediate medical care is
needed, the member’s treating provider may act as the member’s authorized
representative until such time as the member’s authorized representative is
available or until such time as the member is able to appoint an authorized
representative. In this case, the authorized
provider is allowed to file a MCO expedited or standard member appeal. The member’s medical record must demonstrate
that the member was incapacitated and the member’s medical condition required
immediate action prior to the authorized representative being located.
F. “HSD expedited administrative hearing”
means an expedited informal evidentiary hearing conducted by the HSD fair
hearings bureau (FHB) in which evidence may be presented as it relates to an
adverse action taken or intended to be taken, by the MCO. A member or his or her authorized
representative may request a HSD expedited administrative hearing only after
exhausting his or her MCO expedited or standard member appeal process and
unless the request for a HSD expedited administrative hearing is because the
MCO has denied the member’s request for a member appeal to be expedited. See
8.352.2 NMAC for a detailed description of the HSD expedited administrative
hearing process and Subsection B of 8.308.15.13 NMAC.
G. “HSD PASRR administrative hearing”
means a HSD administrative hearing process which is an informal evidentiary
hearing conducted by FHB in which evidence may be presented as it relates to an
adverse action taken or intended to be taken by a MCO of a member’s disputed
PASRR determination, or a member’s disputed transfer or discharge from a
NF. See 8.354.2 NMAC for a detailed
description of the HSD PASRR administrative hearing process.
H. “HSD standard administrative hearing”
means an informal evidentiary hearing conducted by FHB in which evidence may be
presented as it relates to an adverse action taken or intended to be taken, by
the MCO. A member or his or her
authorized representative may request a HSD standard administrative hearing
only after exhausting his or her MCO expedited or standard member appeal
process. See 8.352.2 NMAC for a detailed
description of the HSD standard administrative hearing process.
I. “MAD” means the medical assistance division, which administers
medicaid and other medical assistance programs under HSD.
J. “MAP” means the medical assistance
programs administered under MAD.
K. “MCO” means the member’s HSD contracted
managed care organization.
L. “MCO
expedited member appeal” means the process open to a member or his or her authorized
representative or authorized provider when the member’s MCO has taken or
intends to take an adverse action against the member’s benefit.
(1) A
request for an expedited appeal is appropriate when the MCO, the member, his or
her authorized representative, or the authorized provider believes that
allowing the time for a standard member appeal resolution could seriously
jeopardize the member’s life, health, or his or her ability to attain,
maintain, or regain maximum function.
(2) The process open
to an authorized provider who has requested an authorization or other approval
for the disputed benefit, including a LOC for a member which the MCO has denied
in whole or in part or after the MCO has reconsidered any additional
documentation or information from the authorized provider during the approval
process.
M. “MCO
standard member appeal” means:
(1) the
process open to a member or his or her authorized representative when the
member’s MCO has taken or intends to take an adverse action against the
member’s benefit; or
(2) the process open
to an authorized provider who has requested an authorization or other approval
for the disputed benefit, including a LOC for a member which the MCO has denied
in whole or in part or after the MCO has reconsidered any additional
documentation or information from the authorized provider during the approval
process.
(3) A
MCO cannot change a member’s, or his authorized representative’s or authorized
provider’s request for a MCO expedited or standard member appeal to a MCO
member grievance without the written consent of the appeal requestor.
N. “MCO
member grievance” means an expression of dissatisfaction by a member or his
or her authorized representative about any matter or aspect of the MCO or its
operation that is not included in the definition of an adverse action. A MCO member grievance
final decision does not provide a member the right to request a HSD expedited
or standard administrative hearing, unless the reason for the request is based
on the assertion by the member or his or her authorized representative that the
MCO failed to act within the MCO member grievance time frames.
O. “MCO provider appeal” means the process
open to a provider requesting a review by the MCO of his or her payment,
including denial of a claim for lack of medical necessity or as not a covered
benefit.
P. “MCO
expedited or standard member appeal final decision” means the MCO’s final
decision regarding a member’s or his or her authorized representative’s or
authorized provider’s request for a MCO expedited or standard member appeal of
the MCO’s adverse action it intends to take or has taken against its member.
Q. “MCO
provider grievance” means an expression of dissatisfaction by a provider
about any matter or aspect of the MCO or its operation that is not included in
the definition of an adverse action. The
MCO provider grievance final decision does not allow a provider to request a
HSD provider administrative hearing.
R. “Member” means an eligible recipient
enrolled in a MCO.
S. “Notice of action” means the notice of
an adverse action intended or taken by the member’s MCO.
T. “Provider” means a practitioner or
entity which has delivered or intends to provide a service or item whether the
provider is contracted or not contracted with the member’s MCO at the time services
or items are to be provided.
U. “Valued added services” means services
offered by a MCO that are not part of the MCO’s required benefit package. Disputes concerning value-added services are
not eligible for a MCO appeal or a HSD administrative hearing.
[8.308.15.7
NMAC - Rp, 8.308.15.7 NMAC, 5/1/2018]
8.308.15.8 [RESERVED]
[8.308.15.8
NMAC - Rp, 8.308.15.8 NMAC, 5/1/2018]
8.308.15.9 MCO PROVIDER GRIEVANCE:
A. Upon a provider contracting with the
MCO, the MCO shall provide at no cost a written description of its provider
grievance policies and procedures to the provider. The MCO will notify each of its providers in
writing of any changes to these policies and procedures. The description shall include:
(1) information on how the provider can file a MCO provider
grievance and the MCO’s resolution process;
(2) time frames for each step of the grievance process through
its final resolution; and
(3) a description of how the provider’s grievance is resolved.
B. A provider or
its authorized representative shall have the right to file a grievance with its
MCO to express dissatisfaction about any matter or aspect of the MCO’s operation. The provider or representative may file the
grievance either orally or in writing in accordance with its MCO’s policies and
procedures.
C. The MCO shall
designate a specific employee as its provider grievance manager with the
authority to:
(1) administer the policies, procedures and processes for
resolution of a grievance; and
(2) review patterns and trends in grievances and initiate
corrective action as necessary; and
(3) shall ensure that punitive or retaliatory action is not
taken against any provider that files a grievance.
[8.308.15.9
NMAC - Rp, 8.308.15.9 NMAC, 5/1/2018]
8.308.15.10 MCO PROVIDER APPEALS:
A. Upon
a provider contracting with the MCO, the MCO shall provide at no cost a written
description of its provider appeal policies and procedures and instructions on
how to act as a member’s authorized provider to the provider. The MCO will update in writing each of its
providers with any changes to these policies and procedures. The MCO will additionally provide to a
non-contracted provider who is seeking to or has rendered services or items to
the MCO’s member, policies and procedures informing the provider of his or her
rights and responsibilities to be designated by a member or the member’s
authorized representative to act as his or her authorized provider, and how to
request a MCO expedited or standard member appeal as the authorized provider.
(1) The
description shall include:
(a) information on how the provider can file a MCO provider appeal
and the resolution process;
(b) time frames for each step of the MCO provider appeal process
through its final resolution; and
(c) a description of how the provider’s MCO appeal is resolved.
(2) The MCO shall
designate a specific employee as its provider appeal manager with the authority
to:
(a) administer the policies, procedures and processes for a resolution
of an appeal;
(b) review patterns and trends in appeals and initiate
corrective action; and
(c) ensure that punitive or retaliatory action is not taken
against any provider that files a MCO provider appeal.
B. Standing to request a MCO provider
appeal: A provider or its authorized
representative may request a MCO provider appeal for an intended or taken
adverse action against a provider based on the MCO denial of the provider’s
payment, including a denial of a claim for lack of medical necessity or as not
a covered benefit.
C. Provider rights
and limitations:
(1) A
provider or representative may request a MCO provider appeal either orally or
in writing in accordance with the MCO’s policies and procedures.
(2) A
provider or his or her authorized representative may have its legal counsel or
a spokesperson be a party to the MCO provider appeal
process.
(3) If
the MCO upholds its adverse action in the MCO’s provider appeal final decision,
the appeal process will be considered exhausted. The provider is not eligible
to request a HSD provider administrative hearing. The loss of the appeal does not make the
member liable for any payment to the provider.
[8.308.15.10
NMAC - Rp, 8.308.15.10 NMAC, 5/1/2018]
8.308.15.11 GENERAL INFORMATION ON MCO MEMBER
GRIEVANCES AND APPEALS PROCESSES:
A. Upon a member’s
enrollment:
(1) the
MCO shall provide to the member and his or her authorized representative at no
cost a written description of its member grievance and member expedited and standard
appeal system and member expedited appeal system procedures and processes;
(2) the MCO will promptly provide in writing to each member, his
or her authorized representative any changes to these procedures and
processes. The description shall
include:
(a) information
on how the member or his or her authorized representative or authorized
provider can request a MCO expedited or standard appeal, or how the member or
his or her authorized representative can file a MCO member grievance; and the
resolution processes for each;
(b) time frames for each step of the MCO member grievance and
the MCO expedited and standard member appeal processes through to their final
resolution;
(c) a description of how a MCO member’s grievance or MCO
expedited or standard member appeal is resolved;
(d) information that the MCO may have only one level of appeal
for the member;
(e) in
the case of a MCO that fails to adhere to the time frames for each step of its
procedures and process, the member or his or her authorized representative is
deemed to have exhausted the MCO’s expedited or standard member appeal process
and the member or his authorized representative may request a HSD expedited or
standard administrative hearing.
(f) The MCO shall designate a specific
employee as its member grievance and appeal manager with the authority to:
(i) administer the policies and procedures for resolution of a
MCO member grievance and a MCO expedited or standard member appeal;
(ii) review patterns and trends in MCO member grievances, and MCO
expedited or standard member appeals; and
(iii) ensure that
punitive or retaliatory action is not taken against any member or his or her
authorized representative that files a MCO member grievance or any member, his
or her authorized representative or the authorized provider who requests a MCO
expedited or standard member appeal.
(g) Prior
to the MCO taking an adverse action, in order to avoid incomplete information
during the MCO expedited or standard member appeal process or the HSD expedited
or standard administrative hearing process, the MCO must contact the requesting
provider for more information or justification regarding the request if lack of
information or justification is likely to lead to the adverse action.
B. MCO member
grievance and MCO expedited and standard member appeal rights and responsibilities:
(1) Standing to file
a MCO member grievance:
(a) The
member or his or her authorized representative may file a MCO member grievance
concerning dissatisfaction with the MCO’s operation.
(b) The
member or his or her authorized representative may choose a relative, friend or
other spokesperson to advocate or assist him or her through the MCO member grievance
process; however, the spokesperson is limited to a supporting role and cannot
act on behalf of the member or his or her authorized representative. The member or his or her authorized
representative must provide the MCO a signed release-of-information in order
for the designated spokesperson to have access to information to aid the
spokesperson to assist or advocate for the member or his or her authorized
representative during the MCO’s member grievance process. A member or his or her authorized
representative may elect not to sign such a release, but utilize the spokesperson
during the MCO member grievance process.
(2) The
member or his or her authorized representative may have legal counsel assist
him or her during the MCO member grievance process.
(3) Grievance: A member or his or her authorized
representative shall have the right to file a grievance with his or her MCO to
express dissatisfaction about any matter or aspect of his or her MCO’s
operation other than an adverse benefit determination without time limitations. A MCO member grievance final decision cannot
be appealed through the MCO member appeal process or the HSD administrative hearing
process. If the member or his or her
authorized representative or the authorized provider wishes to appeal an
intended or taken adverse action against the member, the member, his or her
authorized or the authorized provider must comply with all requirements to
request a MCO expedited or standard member appeal including applicable time frames
in which to request a MCO expedited or standard member appeal. A member may file both a MCO member grievance
and a MCO expedited or standard member appeal, but the MCO appeal must meet all
applicable filing time requirements which are not changed by the filing of a
grievance.
(a) The
member or his or her authorized representative may file a MCO member grievance
either orally or in writing in accordance with the MCO’s procedures and
processes.
(b) The
member or his or her authorized representative may file a MCO member grievance
at any time when he or she wishes to register his or her dissatisfaction.
(c) The MCO will
provide the member or his or her authorized representative with its resolution
to the member’s grievance within the time frame specified in the MCO’s medicaid
managed care services agreement.
(4) MCO
expedited or standard member appeal:
A member or his or her authorized representative or the authorized
provider has the right to request a MCO standard member appeal orally and in
writing in accordance with his or her MCO procedures within 60 calendar days of
the date of notice of an intended or taken adverse action. If the request is
orally, it must be followed up in writing within 13 calendar days of the oral
request. A member, his or her authorized
representative or authorized provider has the right to request a MCO expedited
member appeal orally or in writing in accordance with the member’s MCO
procedures within 60 calendar days of the date of the notice of an intended or
taken adverse action.
(a) The
member or his or her authorized representative or the authorized provider may
have legal counsel to assist him or her during the MCO expedited or standard member
appeal process.
(b) Standing
to request a MCO expedited or standard member appeal:
(i) The member or
his or her authorized representative may request a MCO expedited or standard member
appeal concerning his or her disputed benefit.
(ii) The
member, his or her authorized representative or authorized provider may choose
a relative, friend or other spokesperson to advocate or assist him or her
through the MCO expedited or standard member appeal process; however, the
spokesperson is limited to a supporting role and cannot act on behalf of the
member or his or her authorized representative.
The member or his or her authorized representative must provide the MCO
a signed release-of-information in order for a designated spokesperson to have
access to information to aid the spokesperson to assist and advocate for the
member or his or her authorized representative during the MCO expedited or
standard member appeal process.
(c) If
a member or his or her authorized representative or authorized provider elects
to request a continuation of the disputed current benefit, the member, his or
her authorized representative or authorized provider must request a MCO
expedited or standard member appeal and also request a continuation of the
disputed benefit within 10 calendar days of the mailing of the MCO’s notice of
action or before the expected effective date of the MCO’s proposed adverse
action benefit determination, whichever is later. When the mailing date is disputed or there is
a discrepancy between the mailing date and the postmarked date, the postmarked
date will prevail. The member or his or
her authorized representative or authorized provider does not have the right to
request a HSD expedited or standard administrative hearing related to a
value-added services offered by the MCO.
If the member or his or her authorized representative or authorized
provider chooses to request a MCO expedited or standard member appeal, the
following apply.
(i) The
member, his or her authorized representative or authorized provider cannot
request separate appeals. Only one
appeal can be filed.
(ii) If
the MCO upholds its adverse action, regardless of who requested the MCO
expedited or standard member appeal, the MCO expedited or standard member
appeal process is considered exhausted and the member or his or her authorized
representative may request a HSD expedited or standard administrative hearing
concerning his or her disputed benefit.
Once the member or his or her authorized representative requests a HSD
expedited or standard administrative hearing, he or she is referred to as the
claimant. The authorized provider is not
eligible to request a HSD expedited or standard administrative hearing on the disputed
benefit, unless the provider has been designated as
the member’s authorized representative.
See 8.352.2 NMAC for a detailed description of the HSD expedited and
standard administrative hearing processes.
[8.308.15.11
NMAC - Rp, 8.308.15.11 NMAC, 5/1/2018]
8.308.15.12 MCO MEMBER GRIEVANCE PROCESS:
A. The MCO shall provide to its member
or his or her authorized representative reasonable assistance in completing
grievance forms and completing procedural steps, including but not limited to:
(1) providing interpreter services; and
(2) providing toll-free numbers that have adequate TTY/TTD and
interpreter capability.
B. The MCO shall
ensure that the individuals who make decisions related to grievances are not
involved in any previous level of review or decision-making as to the matter
that is grieved.
C. The MCO shall
provide the member or his or her authorized representative with written notice:
(1) when a MCO member grievance request has been received;
(2) of the expected date of resolution which cannot be greater
than 30 calendar days from the date of receipt of the grievance; and
(3) of the final resolution of the grievance.
D. The MCO shall
ensure that punitive or retaliatory action is not taken against any member or authorized
representative that files a grievance, or the member’s provider that supports
the member’s grievance.
[8.308.15.12
NMAC - Rp, 8.308.15.12 NMAC, 5/1/2018]
8.308.15.13 MCO EXPEDITED MEMBER APPEAL PROCESS: The MCO shall establish and maintain an expedited
review process for a MCO expedited member appeal when the MCO, the member or
his or her authorized representative or authorized provider believes that
allowing the time for a standard member appeal resolution could seriously
jeopardize the member’s life, health, or his or her ability to attain,
maintain, or regain maximum function.
Once a member or his or her authorized representative or authorized
provider requests a MCO expedited member appeal and the member or his or her
authorized representative or authorized provider requests a continuation of the
member’s disputed current benefit, the MCO will grant a continuation of the
disputed current benefit until the MCO expedited member appeal final decision
is rendered by the MCO. However, if the
date of the MCO expedited member appeal final decision letter is prior to the
notice of action’s adverse action effective date, the MCO must continue the
disputed current benefit up to the adverse action’s effective date. The MCO shall ensure that health care
professionals with appropriate clinical expertise in addressing the physical
health, behavioral health, or long-term services and supports needs of the
member are utilized during the MCO expedited member appeal process when the MCO
notice of action for the disputed benefit is based on a lack of medical
necessity.
A. A member or his or her authorized
representative or authorized provider in accordance with the member’s MCO
procedures has the right to request within 60 calendar days after the mailing
of the MCO’s notice of action a MCO expedited member appeal orally or in
writing. When the mailing date of the
notice of action is disputed or there is a discrepancy between the mailing date
and the postmarked date, the postmarked date will prevail.
(1) If
a member, his or her authorized representative or authorized provider elects to
request a continuation of the member’s disputed current benefit, the member or
his or her authorized representative or authorized provider must request a MCO
expedited member appeal and request a continuation of the member’s disputed
current benefit within 10 calendar days of the mailing of the MCO’s notice of
action. When the mailing date of the
notice of action is disputed or there is a discrepancy between the mailing date
and the postmarked date, the postmarked date will prevail. The continuation of the disputed current benefits
is not dependent on the approval to proceed to the MCO expedited appeal process. See 8.308.15.15 NMAC for a detailed
description of the continuation of the disputed benefit process.
(2) If
the member or authorized representative or authorized provider requests a MCO
expedited member appeal, the following applies.
(a) If
the member or his or her authorized representative designate in writing the
member’s provider to act as the member’s authorized provider, the authorized provider
may request a MCO expedited member appeal when the authorized provider believes
that the MCO has made an incorrect decision concerning the member’s disputed
benefit.
(b) If
the MCO upholds its adverse action, regardless of who requested the MCO
expedited member appeal process, the MCO expedited member appeal process is
considered exhausted and the member or his or her authorized representative may
request a HSD expedited or standard administrative hearing concerning the
member’s disputed benefit.
(c) Once
the member or his or her authorized representative request a HSD expedited or
standard administrative hearing, he or she is referred to as the claimant.
(4) The
member or his or her authorized representative or the authorized provider may
have legal counsel or a spokesperson assist him or her during the MCO expedited
member appeal process.
(5) The
member or his or her authorized representative or the authorized provider does
not have the right to request a MCO expedited or standard member appeal or a
HSD expedited or standard administrative hearing related to a value-added
service offered by the MCO.
(6) The
authorized provider is not eligible to request a HSD expedited or standard
administrative hearing on the disputed benefit, unless
the provider has been designated as the member’s authorized
representative. See 8.352.2 NMAC for a
detailed description of the HSD expedited and standard administrative hearing
processes.
B. The request for a MCO expedited
member appeal may be made orally or in writing to the member’s MCO within the
required time frame. The reasons why a
MCO expedited member appeal is necessary must be detailed in the oral or
written request. A member’s provider
(regardless if the provider is not the authorized provider) may assist the
member or his or her authorized representative in stating the reasons and
providing supporting documentation that a MCO expedited member appeal is
medically necessary. There can only be
one MCO member appeal request concerning the disputed benefit at one time. If the MCO denies the request for a MCO
expedited member appeal, the member or his or her authorized representative may
then request a HSD expedited or standard administrative hearing regarding the
issue of the denial of a MCO expedited member appeal. See 8.352.2 NMAC for a detailed description
of the HSD expedited and standard administrative hearing processes.
C. The MCO shall designate a specific
employee as its MCO expedited member appeal manager with the authority to:
(1) administer the policies and procedures for resolution of a
MCO expedited member appeal;
(2) review patterns and trends in member expedited appeals and
initiate corrective action; and
(3) ensure there
is no punitive or retaliatory action taken against any member, his or her
authorized representative or authorized provider that files an expedited MCO
member appeal, or a provider that supports the member’s appeal.
D. The MCO shall provide reasonable
assistance to the member or his or her authorized representative or the
authorized provider requesting a MCO expedited member appeal in completing
forms and completing procedural steps, including but not limited to:
(1) providing interpreter services;
(2) providing toll-free numbers that have adequate TTY/TTD and
interpreter capability; and
(3) assisting the member, his or her authorized representative
or the authorized provider in understanding the MCO rationale regarding the
disputed benefit which was wholly denied, partially denied or that was limited
in order to ensure that the issue under expedited appeal is sufficiently
defined throughout the MCO expedited member appeal.
E. The MCO shall
provide in writing to the member, his or her authorized representative, and the
member’s provider (regardless if the provider is not the authorized provider)
with the following information once a request is made for a MCO expedited
member appeal:
(1) the
date the MCO expedited member appeal request was received by the MCO, and the
MCO’s understanding of what the member or his or her authorized representative
or the authorized provider is appealing concerning the member’s disputed
benefit;
(2) the expected date of the MCO member appeal decision:
(a) that is not to exceed 72 hours from
the date of the receipt of the request for a MCO expedited member appeal; and
(b) that alerts the member or his or her authorized
representative or the authorized provider of the possibility of an appeal extension
of up to an additional 14 calendar days when:
(i) the member or his or her authorized representative or
authorized provider requests the extension; or
(ii) the MCO determines it requires additional information and
provides a written justification to the member or his or her authorized
representative or authorized provider, and also places in the member’s MCO
expedited member appeal file how the extension is in the best interest of the
member.
F. Time frames:
(1) The
MCO must act as expeditiously as the member’s condition requires, but no later
than 72 hours after receipt of a request for a MCO expedited member appeal, and
provide the member and his or her authorized representative and the authorized
provider its MCO expedited member appeal final decision. The MCO must also make reasonable efforts to
provide oral notice of the decision.
(2) If
the member or his or her authorized representative or the authorized provider
requests an extension of the decision date, the MCO shall extend the 72-hour
time period up to 14 calendar days to allow the member or his or her authorized
representative or the authorized provider to submit additional documentation to
the MCO supporting the need for the MCO expedited member appeal.
(3) The
MCO may itself extend the 72-hour time period when it determines there is a
need to collect and review additional information prior to rendering its MCO
expedited member appeal final decision.
The MCO must provide justification in writing to the member or his or
her authorized representative or the authorized provider and also place in the
member’s expedited member appeal file how the extension of time is in the
member’s best interest.
(4) A
member or his or her authorized representative may file a MCO member grievance against
the MCO’s decision to extend the 72-hour time frame and up to an additional 14
calendar days.
G. MCO-initiated expedited MCO member
appeal: When the MCO determines that
allowing the time for a standard MCO member appeal process could seriously
jeopardize the member’s life, health, or his or her ability to attain,
maintain, or regain maximum function, the MCO shall:
(1) automatically file a MCO-initiated expedited member appeal
on behalf of the member and continue the disputed current benefit without cost
to the member if the MCO-initiated expedited member appeal final decision
upholds the MCO adverse action;
(2) make
reasonable efforts to provide the member, his or her authorized representative
and the member’s provider (regardless if the provider is not the authorized
provider) prompt oral notice of the automatic appeal, following up as
expeditious as possible, but within 72 hours of the MCO expedited member appeal
final decision; and
(3) use its best effort to involve the member, his or her
authorized representative and the member’s provider (regardless if the provider
is not the authorized provider) in the member’s MCO-initiated expedited member
appeal. The member’s MCO expedited
appeal record will contain the dates, times, and methods the MCO utilized to
contact the member, his or her authorized representative or the authorized
provider, or another provider of the member.
If the MCO-initiated member appeal final decision upholds the MCO’s
adverse action, the MCO member appeal process is exhausted and the member or
his or her authorized representative may request a HSD expedited or standard
administrative hearing.
[8.308.15.13
NMAC - Rp, 8.308.15.13 NMAC, 5/1/2018]
8.308.15.14 MCO STANDARD MEMBER APPEAL PROCESS:
A. A
member or his or her authorized representative or the authorized provider in
accordance with the member’s MCO procedures has the right to request within 60
calendar days after the mailing of the MCO’s notice of action a MCO standard
member appeal orally and in writing. When
the mailing date of the notice of action is disputed or there is a discrepancy
between the mailing date and the postmarked date, the postmarked date will
prevail. If orally requested, the
request must be followed up in writing within 13 calendar days of the oral
request.
(1) If a member or his or her authorized
representative or authorized provider elects to request a continuation of the
member’s disputed current benefit, the member or his or her authorized
representative or the authorized provider must request a MCO standard member
appeal and request a continuation of the member’s disputed current benefit
within 10 calendar days of the mailing of the MCO’s notice of action. When the mailing date of the notice of action
is disputed or there is a discrepancy between the mailing date and the postmarked
date, the postmarked date will prevail.
See 8.308.15.15 NMAC for a detailed description of the continuation of
the disputed current benefit process.
(2) If
the member or his or her authorized representative or the authorized provider
requests a MCO standard member appeal, the following apply.
(a) If
the member or his or her authorized representative designate in writing the
member’s provider to act as the member’s authorized provider, the authorized
provider may request a MCO standard member appeal when the authorized provider
believes that the MCO has made an incorrect decision concerning the member’s
disputed benefit.
(b) If
the MCO upholds its adverse action, regardless of who requested the MCO
standard member appeal process, the MCO standard member appeal process is
considered exhausted and the member or his or her authorized representative may
request a HSD expedited or standard administrative hearing concerning the
member’s disputed benefit.
(c) If
a member or his or her authorized representative elects not to request a HSD
expedited or standard administrative hearing, and if the date of the MCO standard
member appeal final decision letter is prior to the notice of action’s adverse
action effective date, the MCO must continue the disputed current benefit up to
the notice of action’s adverse action effective date.
(d) Once
the member or his or her authorized representative requests a HSD expedited or
standard administrative hearing, he or she is referred to as the claimant.
(3) The
member or his or her authorized representative or the authorized provider may
have legal counsel or a spokesperson assist him or her during the MCO standard
member appeal process.
(4) The
member or his or her authorized representative or the authorized provider does
not have the right to request a MCO expedited or standard member appeal or a
HSD expedited or standard administrative hearing related to a value-added
service offered by the MCO.
(5) The
authorized provider is not eligible to request a HSD expedited or standard
administrative hearing on the disputed benefit, unless
the provider has been designated as the member’s authorized
representative. See 8.352.2 NMAC for a
detailed description of the HSD expedited or standard administrative hearing
processes.
B. The MCO shall designate a specific
employee as its MCO standard member appeal manager with the authority to:
(1) administer the policies and procedures for resolution of a
MCO standard member appeal;
(2) review patterns and trends in standard member appeals and
initiate corrective action; and
(3) ensure there
is no punitive or retaliatory action taken against any member or his or her
authorized representative or authorized provider that files a MCO standard
member appeal, or a provider that supports the member’s appeal.
C. The MCO shall provide reasonable
assistance to the member or his or her authorized representative or the
authorized provider requesting a MCO standard member appeal in completing forms
and completing procedural steps, including but not limited to:
(1) providing interpreter services;
(2) providing toll-free numbers that have adequate TTY/TTD and
interpreter capability; and
(3) assisting the member or his or her authorized representative
or the authorized provider in understanding the MCO rationale regarding the
disputed benefit which was wholly denied, partially denied or that was limited
in order that the issue under appeal is sufficiently defined throughout the MCO
standard member appeal.
D. The MCO shall
provide the member or his or her authorized representative, and the member’s
provider (regardless if the provider is not the authorized provider) with the
following information once a request is made for a MCO standard member appeal.
(1) The
date the MCO standard member appeal request was received by the MCO, and the
MCO’s understanding of what the member or his or her authorized representative
or the authorized provider is appealing concerning the member’s disputed
benefit;
(2) The
expected date of the MCO standard member appeal decision:
(a) that is not to exceed 30 calendar
days from the date of the receipt of the request for a MCO standard member
appeal; and
(b) that alerts the member or his or her authorized
representative or the authorized provider of the possibility of an appeal
extension of up to an additional 14 calendar days when:
(i) the member or his or her authorized representative or
authorized provider requests the extension; or
(ii) the MCO determines it requires additional information and
provides to the member or his or her authorized representative or authorized
provider, and also places in the member’s MCO standard member appeal file how
the extension is in the best interest of the member.
E. Time frames:
(1) The
MCO must act as expeditiously as the member’s condition requires, but no later
than 30 calendar days after receipt of a request for a MCO standard member
appeal, and provide the member or his or her authorized representative or the
authorized provider its MCO standard member appeal final decision.
(2) If
the member or his or her authorized representative or the authorized provider
requests an extension of the decision date, the MCO shall extend the 30
calendar day time period up to an additional 14 calendar days to allow the
member or his or her authorized representative or the authorized provider to
submit additional documentation to the MCO supporting the medical necessity for
the disputed benefit.
(3) The
MCO may itself extend the final decision up to the additional 14 calendar day
time period when it determines there is a need to collect and review additional
information prior to rendering its MCO standard member appeal final
decision. The MCO must provide
justification in writing to the member or his or her authorized representative
or the authorized provider and also place in the member’s clinical file how the
extension of time is in the member’s best interest.
(4) A
member or his or her authorized representative may file a MCO member appeal or
grievance against the MCO’s decision to extend the 30 calendar day time frame
up to an additional 14 calendar days.
[8.308.15.14
NMAC - Rp, 8.308.15.14 NMAC, 5/1/2018]
8.308.15.15 CONTINUATION OF A DISPUTED CURRENT BENEFIT
DURING THE MCO EXPEDITED AND STANDARD MEMBER APPEAL PROCESSES: A member or his
or her authorized representative or authorized provider requesting a MCO
expedited or standard member appeal of an adverse action may request that the
disputed current benefit continue during the MCO expedited or standard member
appeal process. However, if the date of
the MCO expedited or standard member appeal final decision letter is prior to
the effective date of the notice of action’s adverse action effective date, the
MCO must continue the disputed current benefit up to the notice of action’s adverse
action effective date.
A. A request for a continuation of the
disputed current benefit shall be accorded to any member who or through the
member’s authorized representative or authorized provider requests the
continuation of the disputed current benefit who also requests a MCO expedited
or standard member appeal within 10 calendar days of the mailing of the notice
of action or prior to the date the notice of action states the benefit will be
terminated. When the mailing date of the
notice of action is disputed or there is a discrepancy between the mailing date
and the postmarked date, the postmarked date will prevail.
B. The
continuation of a disputed current benefit is only available to a member who is currently receiving the
disputed benefit at the time of the MCO’s notice of action.
(1) The continuation
of the disputed current benefit is the same as the member’s current benefit, which includes the member’s current allocation, budget or LOC.
(2) The MCO must
provide written information in its notice of action of the member’s or his or
her authorized representative’s or authorized provider’s rights and
responsibilities to continue the disputed current benefit during the MCO
expedited or standard member appeal process and of the possible responsibility
of the member to repay the MCO for the disputed current benefit if the MCO expedited
or standard member appeal final decision upholds the MCO’s adverse action. If it was a MCO-initiated expedited member
appeal, the MCO cannot recover the cost of the disputed current benefit if the
MCO’s adverse action is upheld.
C. A
member or his or her authorized representative or authorized provider has the
right to not request a continuation of the disputed current benefit during the
MCO expedited or standard member appeal process.
[8.308.15.15
NMAC - Rp, 8.308.15.15 NMAC, 5/1/2018]
8.308.15.16 MCO EXPEDITED MEMBER APPEAL AND MCO STANDARD
MEMBER APPEAL FINAL DECISION AND IMPLEMENTATION:
A. The MCO shall provide the member or his
or her authorized representative and the provider (regardless if the provider
was not the one requesting the MCO member appeal) with its MCO expedited or
standard member appeal final decision within the required time frames and
provide supporting documentation substantiating the MCO’s decision.
B. When the MCO expedited or standard
member appeal final decision reverses the MCO’s adverse action in total and the
disputed benefit was not furnished during the member’s expedited or standard
member appeal process, the MCO shall authorize or provide the disputed benefit
promptly and as expeditiously as the member’s health condition requires.
C. When the MCO expedited or standard
member appeal final decision reverses the MCO’s adverse action in total and the
member, his or her authorized representative or authorized provider had
requested and the member had received a continuation of the disputed current
benefit during the MCO expedited or standard member appeal process, the MCO may
not recover from the member the cost of the continued disputed current benefit
furnished during the MCO expedited or standard member appeal process.
D. When the MCO
expedited or standard member appeal final decision upholds the MCO’s adverse
action and the member or his or her authorized representative or authorized
provider had requested and the member had received a continuation of the
disputed current benefit, the MCO may recover from the member the cost of the
disputed current benefit furnished during the MCO expedited or standard member
appeal process if:
(1) the
member, his or her authorized representative or authorized provider was
informed in writing by the MCO that the member could be responsible for the
cost of the disputed current benefit if the MCO expedited or standard member
appeal final decision upholds the MCO adverse action; and
(2) the member or his or her authorized representative elects
not to request a HSD expedited or standard administrative hearing of the
disputed current benefit.
(3) A
MCO cannot recover the cost of the continued disputed benefit regardless if the
final decision is upheld or reverses the MCO adverse action when the MCO initiated
the MCO expedited member appeal process.
See Subsection E of 8.308.15.13 NMAC for detailed description of a MCO-initiated
expedited member appeal process.
E. A member or his
or her authorized representative may request a HSD expedited or standard
administrative hearing if the MCO expedited or standard member appeal decision
does not reverse in total the MCO’s adverse action as the member or his or her
authorized representative has now exhausted the MCO expedited or standard
member appeal process. The authorized
provider cannot request a HSD expedited or standard administrative hearing on
his or her own; this right is accorded only to the member or his or her
authorized representative, unless the provider has been designated as the
member’s authorized representative.
F. A member or his
or her authorized representative must request a HSD expedited administrative
hearing within 30 calendar days of the date of the MCO member appeal final
decision letter or request a HSD standard administrative hearing within 90 days
of the date of the MCO member appeal final decision.
(1) A member or his
or her authorized representative or authorized provider may request and the
member receive a continuation of the disputed current benefit at any time prior
to the MCO notice of action’s intended date the disputed benefit will be
terminated. The request may be made even
after the MCO expedited or standard member appeal final decision letter is
issued if issued before the date the disputed benefit will be terminated.
(2) If the member
received a continuation of his or her disputed current benefit during the MCO
member appeal process, the member or his or her authorized representative does
not need to request another continuation of the disputed current benefit when
requesting a HSD expedited or standard administrative hearing. It is automatically continued by the member’s
MCO.
(3) If
the member or his or her authorized representative chooses to discontinue the disputed
current benefit that is being provided during the MCO expedited or standard
member appeal process or during the HSD expedited or standard administrative
hearing process, the member or his or her authorized representative must notify
the member’s MCO in writing stating the date the disputed current benefit will
end.
G. When the MCO
expedited or standard member appeal final decision upholds the MCO’s adverse
action in total or in part and the member or his or her authorized representative
or authorized provider had requested and the member had received the disputed
current benefit during the MCO member appeal, and the member or his or her
authorized representative elects to continue the member’s disputed current
benefit during the member’s HSD expedited or standard administrative hearing
process, the MCO must in writing inform the member or his or her authorized
representative that if the HSD expedited or standard administrative hearing
final decision upholds the MCO’s adverse action, the member could be
responsible for the cost of the disputed current benefit during MCO expedited
or standard member appeal process and the HSD expedited or standard administrative
hearing process.
H. If the member or
his or her authorized representative requests a HSD expedited or standard
administrative hearing and the member or his or her authorized representative
or authorized provider requested and the member received the disputed current
benefit during the MCO member appeal process, the MCO will not take action to
recover the costs of the continued disputed current benefit until there is a
HSD expedited or standard administrative hearing final decision upholding the
MCO adverse action.
I. If the member’s
MCO had automatically filed a MCO-initiated expedited member appeal on behalf
of the member to continue the disputed current benefit during the MCO expedited
member appeal process, the MCO cannot take action to recover the costs of the
continued disputed current benefit if the MCO expedited member appeal final
decision upholds the MCO’s adverse action.
However, if the member or his or her authorized representative wants to
continue the disputed current benefit during the HSD expedited or standard
administrative hearing, the member could be responsible for the cost of the
continued disputed current benefit starting on the first calendar day the
member or the authorized representative requested a HSD expedited or standard
administrative hearing and requested the continuation of the disputed current
benefit.
J. See 8.352.2
NMAC for a detailed description of the HSD expedited and standard
administrative hearing processes and for a detailed description of the MCO
recovery process.
[8.308.15.16
NMAC Rp, 8.308.15.16 NMAC, 5/1/2018]
HISTORY OF
8.308.15 NMAC:
History of
Repealed Material:
8.308.15
NMAC, Grievances and Appeals - Repealed 6/15/2014.
8.308.15 NMAC - Managed Care
Program, Grievances and Appeals, filed 5/27/2014 Repealed effective 5/1/2018.