N.M. Admin. Code § 13.10.16.8 - GENERAL RULES
A carrier shall adopt and implement a provider grievance plan that complies with this rule. This rule does not preclude a carrier and provider from addressing or resolving a concern through any other process agreed on between them, but no such alternative process shall preclude a provider from presenting a grievance through a process that complies with this rule.
A.
Allowed
grievances. At a minimum, a carrier's provider grievance plan shall
allow a provider to present any concern regarding:
(1) credentialing deadlines;
(2) claim payment amount or timing;
(3) claim submission requirements or
compliance;
(4) network adequacy,
including participation determinations based on network composition;
(5) network composition including provider
qualifications;
(6) utilization
management practices;
(7) provider
contract construction or compliance;
(8) patient care standards or access to
care;
(9) surprise billing
reimbursement amount, rate or timing;
(10) termination;
(11) operation of the plan including
compliance with any law enforceable by the superintendent, or of any directive
of the superintendent; or
(12)
Discrimination.
B.
Timeline to file. A provider grievance plan shall allow a provider
at least 90 days from the incident that is the subject of the grievance, to
file a grievance.
C.
Filing
procedures and response. A provider grievance plan shall allow a
provider to submit a written grievance electronically or manually. A carrier
shall send a written acknowledgment of the grievance to the provider within
five days of its receipt of the grievance using the provider's preferred
communication method.
D.
Point of contact. A provider grievance plan may require the
submission of a complaint to a designated contact, as specified in the
carrier's provider manual which shall identify the designated contact by name
or position and provide a valid mailing address, phone number, and email
address for the designated point of contact.
E.
Request for supplemental
information. A provider grievance plan may allow a carrier to request
supplemental information pertinent to the resolution of a grievance from the
provider. Any such request shall be made within 10 days of the carrier's
receipt of a grievance, and shall require the provider to submit the requested
supplemental information within the next 10 days.
F.
Review panel. A provider
grievance plan shall, at a minimum, require a carrier to form a review panel
comprised of multiple members, at least one of whom is in a position of
authority over the carrier operations that are the subject of a grievance. The
review panel shall be responsible for reviewing and deciding the provider's
grievance. If the grievance raises a quality-of-care concern the panel must
include a New Mexico-licensed medical professional who practices in the general
area of concern. A New Mexico-licensed physician shall be included on a review
panel considering complex quality-of-care concerns. No person with a conflict
of interest shall participate in a decision to resolve a grievance. Employment
with the carrier, standing alone, does not present a conflict of
interest.
G.
Response.
A provider grievance plan shall require a carrier to deliver a written
response, to a grievance using the provider's preferred method of communication
within 45 days of the later of receipt of the grievance, receipt of
supplemental information requested to resolve the grievance, or the due date
for submission of any requested supplemental information. The response shall
include:
(1) the name(s), title(s), and
qualification(s) of each person who participated in the grievance
decision;
(2) a statement of
issue(s) decided and of the ultimate decision(s);
(3) a clear and complete explanation of the
rationale for the decision and a summary of the evidence relied upon to support
the decision;
(4) a summary of any
proposed remedial action; and
(5)
information on the provider's appeal rights.
H.
Extension of deadlines. If
confirmed in a documented communication a carrier and provider may agree to
extend any deadline imposed by this rule or a provider grievance
plan.
I.
Presentation of
evidence. A provider grievance plan shall include reasonable procedures
by which a provider may present oral or documentary evidence to the assigned
grievance panel.
J.
Bundled
or group grievances. A provider grievance plan shall allow a provider to
submit multiple related grievances simultaneously provided the grievances are
not unduly duplicative or repetitive, and for a group of providers to assert a
single grievance on behalf of multiple providers.
K.
Non-participating providers.
A carrier's provider grievance plan shall allow a non-participating provider to
submit a grievance described in Paragraphs (1), (2), (4), (5), (6), (9) or (12)
of Subsection A of this section. The grievance must assert and explain that the
carrier's act or practice directly impacted the non-participating provider or a
patient of that provider.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.