A.
Notice
requirements. The health care insurer shall notify the grievant and
provider of the decision within 24 hours by telephone and in writing by mail or
electronic communication sent within one day after the initial attempt to
provide telephonic notice, unless earlier notice is required by the medical
exigencies of the case.
B.
Contents of notice. If the initial decision denying certification
is upheld in whole or in part, then the health care insurer's notice shall
include the following:
(1) the name, title
and qualifying credentials of the person who provided the review;
(2) a statement of the reviewer's
understanding of the nature of the grievance;
(3) a description of the evidence relied on
by the reviewer in reaching a decision;
(4) if an adverse determination is upheld
based on a determination that the requested service is experimental,
investigational or not medically necessary, then:
(a) clearly and completely explain why the
requested health care service is not medically necessary, is experimental or
investigational; a statement that the health care service is not medically
necessary, is experimental or investigational will not be sufficient;
and
(b) include a citation to the
uniform standards relevant to the grievant's medical condition and an
explanation of whether each standard supported or did not support the
determination that the requested service is experimental, investigational, or
is not medically necessary.
(5) if an adverse determination is upheld
based on a lack of coverage, identify all health benefits plan provisions
relied on in making the adverse determination, and clearly and completely
explain why the requested health care service is not covered by any provision
of the health benefits plan; a statement that the requested health care service
is not covered by the health benefits plan will not be sufficient;
(6) if the service has already been provided,
then include the date of service, the provider, the claim amount (if
applicable), and a statement describing the availability, upon request, of the
diagnosis code and its corresponding meaning, and the treatment code and its
corresponding meaning;
(7) notice
that the grievant may request either:
(a) an
internal panel review within 15 days; or
(b) an external review within four
months.
(8) if the
adverse determination involves an urgent care situation, advise that the
grievant may immediately request an expedited IRO external review;
(9) if the grievant is covered by the New
Mexico Health Care Purchasing Act, then advise the grievant that an internal
panel review is required before the grievance will be reviewed by the
grievant's specific review board and only then may the grievant request an
external review; and
(10) describe
the procedures and provide all necessary grievance forms to the grievant for
requesting an internal panel review, for requesting an external review, or for
requesting an expedited review.
C.
Information for requesting an
external review. Notice of the grievant's right to request an external
review shall include the address and telephone number of the MHCB, a
description of all procedures and time deadlines necessary to pursue an
external review, copies of all forms required to initiate an external review
and the following notice:
"We have denied your request for the provision of or
payment for a health care service or course of treatment. You may have the
right to have our decision reviewed, at no cost to you, by an impartial
Independent Review Organization (IRO) who has no association with us and is
appointed by the Office of Superintendent of Insurance (OSI). If our decision
involved making a judgment as to the medical necessity, experimental nature or
investigational nature of the requested service, or the appropriateness, health
care setting, or level of care, then the Independent Review Organization (IRO)
review will be performed by one or more health care professionals. You may also
request an external review by OSI for rescissions or for adverse determinations
that do not involve medical judgment. For more information contact OSI by
electronic mail at mhcb.grievance@osi.nm.gov; by telephone at (505) 827-4601;
or toll- free at 1-(855)-427-5674. You may also visit the OSI website at
http://www.osi.state.nm.us for
more information."
D.
Grievance discontinued. If
the grievant informs the health care insurer by telephone that the grievant
does not wish to pursue the grievance, then the health care insurer's notice
shall include confirmation of the grievant's decision not to pursue the matter
further.
E.
Grievant's
decision unknown. If the health care insurer is unable to contact the
grievant by telephone within one day of the decision to uphold the adverse
determination, the health care insurer's written notice shall include a
self-addressed stamped envelope and response form which asks whether the
grievant wishes to request either an internal panel review or an external
review. The form shall provide check boxes as follows:
Do you want to appeal the decision?
[] No o Yes (If yes, then please select one of the
following:)
[] Internal panel review requested
[] External review requested
F.
Extending the timeframe for
requesting a standard review. If the grievant does not make an immediate
decision to pursue the grievance, or the grievant has requested additional time
to supply supporting documents or information, or postponement pursuant to
Subsection F of
13.10.17.14 NMAC, the timeframe
shall be extended to include the additional time if requested by the
grievant.
Notes
N.M. Admin.
Code §
13.10.17.15
Adopted by
New
Mexico Register, Volume XXVII, Issue 23, December 15, 2016, eff.
1/1/2017, Amended by
New
Mexico Register, Volume XXXV, Issue 22, November 19, 2024, eff.
11/19/2024
