TITLE 8 SOCIAL SERVICES

CHAPTER 350 RECONSIDERATION OF UTILIZATION REVIEW

PART 4 RECONSIDERATION OF AUDIT SETTLEMENTS

8.350.4.1 ISSUING AGENCY: New Mexico Human Services Department.

[1/1/95; 8.350.4.1 NMAC - Rn, 8 NMAC 4.MAD.000.1, 1/1/03]

8.350.4.2 SCOPE: The rule applies to the general public.

[1/1/95; 8.350.4.2 NMAC - Rn, 8 NMAC 4.MAD.000.2, 1/1/03]

8.350.4.3 STATUTORY AUTHORITY: The New Mexico Medicaid program is administered pursuant to regulations promulgated by the federal Department of Health and Human Services under Title XIX of the Social Security Act, as amended and by the state Human Services Department pursuant to state statute. See NMSA 1978 Section 27-2-12 et. seq. (Repl. Pamp. 1991).

[1/1/95; 8.350.4.3 NMAC - Rn, 8 NMAC 4.MAD.000.3, 1/1/03]

8.350.4.4 DURATION: Permanent.

[1/1/95; 8.350.4.4 NMAC - Rn, 8 NMAC 4.MAD.000.4, 1/1/03]

8.350.4.5 EFFECTIVE DATE: November 1, 1996.

[1/1/95, 2/1/95; 8.350.4.5 NMAC - Rn, 8 NMAC 4.MAD.000.5, 1/1/03]

8.350.4.6 OBJECTIVE: The objective of these regulations is to provide policies for the service portion of the New Mexico Medicaid program. These policies describe eligible providers, covered services, noncovered services, utilization review, and provider reimbursement.

[1/1/95, 2/1/95; 8.350.4.6 NMAC - Rn, 8 NMAC 4.MAD.000.6, 1/1/03]

8.350.4.7 DEFINITIONS: [RESERVED]

8.350.4.8 MISSION STATEMENT: The mission of the New Mexico Medical Assistance Division (MAD) is to maximize the health status of Medicaid-eligible individuals by furnishing payment for quality health services at levels comparable to private health plans.

[2/1/95; 8.350.4.9 NMAC - Rn, 8 NMAC 4.MAD.002, 1/1/03]

8.350.4.9 RECONSIDERATION OF AUDIT SETTLEMENTS:

A. General Reconsideration Process: Medicaid providers who disagree with an audit settlement can submit a written request for a reconsideration to the New Mexico Medical Assistance Division (MAD) within thirty (30) calendar days of the date on the notice of final settlement. The written request may be submitted by facsimile or by U.S. mail but not by electronic mail. The written request must be received by MAD no later than the thirtieth day from the date of the notice. Filing of a request for reconsideration does not affect the imposition of the final settlement.

(1) Information Included in the Request: The written request for reconsideration must identify each point on which the provider takes an issue with the audit agent and include all documentation, citations of authority, and arguments on which the request is based. Any point or issue not raised in the original request for reconsideration may not be raised later and will not be considered in the final decision of the reconsideration.

(2) Audit Agent Response: The written request and supporting materials is forwarded to the audit agent for reconsideration. The audit agent must file a response with MAD within thirty (30) calendar days of the receipt of the request and supporting material from MAD.

(3) Submission of Additional Material: MAD forwards the audit agent's response to the provider. Additional material from the audit agent or the provider must be received by MAD within fifteen (15) calendar days of the date the response was forwarded to the provider. Any additional information, the request for reconsideration and supporting documentation, and the audit agent's response constitute final submittal. The packet containing the final submittal is provided to the MAD Deputy Director for final submittal by the responsible bureau for program reimbursement.

(4) Decision by MAD: The Deputy Director may call on all information and call on all expertise he/she believes is necessary to decide the issue. The Deputy Director makes a determination and submits a written copy of his/her findings to each party within forty-five (45) calendar days of the date of final submittal to the MAD Director. The decision may be sent to the parties by facsimile or U.S. mail. The provider may appeal an adverse decision on the request for reconsideration to the New Mexico Human Services Department’s Hearings Bureau pursuant to the 8.353.10 NMAC. The MAD Director or designee shall make the decision on the recommendation from the hearing officer.

B. Specific Reconsideration Process for Nursing Facility, Intermediate Care Facility for the Mentally Retarded Providers: The reconsideration process for audit settlement varies for the aforementioned providers. See 8.312.3 NMAC, COST RELATED REIMBURSEMENT FOR NURSING FACILITIES, and 8.313.3 NMAC, COST RELATED REIMBURSEMENT OF ICF/MR FACILITIES for specific information.

[11/1/96; 8.350.4.9 NMAC - Rn, 8 NMAC 4.MAD.955 & A, 1/1/03]

HISTORY OF 8.350.3 NMAC: [RESERVED]