N.M. Admin. Code § 13.10.16.9 - PROVIDER TERMINATION
For a grievance that concerns a termination a provider grievance plan shall also comply with this section.
A.
Terminations for cause. If a
termination for cause, the provider grievance plan shall provide a fair hearing
process that provides these minimum rights and protections:
(1) the right of the provider to appear in
person at a hearing before the deciding panel;
(2) the right of the provider to present
testimonial or documentary evidence at the hearing;
(3) the right of the provider to call
witnesses, and cross-examine any witness;
(4) the right of the provider to be
represented by an attorney or by any other person of the provider's
choice;
(5) the right to an
expedited hearing within 14 days of the termination in those instances where
the carrier has not provided advance written notice of termination and the
termination could result in imminent and significant harm to a covered
person;
(6) a written decision
within 20 days after the hearing, contemporaneously delivered via the
provider's preferred method of communication; and
(7) if a group of providers is terminated for
cause, each provider in the group shall have an individual right to a hearing.
However, if any one of the providers in the group submits a grievance relating
to the termination the carrier shall provide each similarly situated provider
in the group with a notice of hearing, and each provider who receives such
notice shall be bound by the carrier's determination subject to any appeal
rights.
B.
Other
terminations. If a termination is not for cause, the provider grievance
plan shall require the carrier to furnish the provider written notice at least
60 days before the effective date of termination. Such notice shall:
(1) be communicated in writing via the format
preferred by the provider; and
(2)
contain an explanation of the termination.
Notes
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