N.M. Admin. Code § 13.10.17.19 - IRO REVIEW OF AN ADVERSE DETERMINATION
A.
Right to external IRO review.
Every grievant who is dissatisfied with an adverse determination following
internal review of a grievance that involves medical judgment, including a
determination based on medical necessity, appropriateness, health care setting,
level of care, effectiveness or that the requested health care service is
experimental, investigational or unproven for a particular medical condition
may request an external review by an impartial IRO appointed by the
superintendent at no cost to the grievant.
B.
Exhaustion of internal review
process. The superintendent may require the grievant to exhaust any
required grievance procedures Amended by the health care insurer or the entity
that purchases health care benefits pursuant to the New Mexico Health Care
Purchasing Act, as appropriate, before accepting a grievance for IRO
review.
C.
Deemed
exhaustion. If exhaustion of internal reviews is required prior to IRO
review, exhaustion is unnecessary and the internal reviews process will be
deemed exhausted if:
(1) the health care
insurer waives the exhaustion requirement;
(2) the health care insurer is considered to
have exhausted the internal review process by failing to comply with the
requirements of the internal review process; or
(3) the grievant simultaneously requests an
expedited internal review and an expedited IRO review.
D.
Exception to exhaustion
requirement.
(1) Notwithstanding
Subsection C of
13.10.17.19 NMAC, the internal
review process will not be deemed exhausted based on violations by the health
care insurer that are de minimus and do not cause, and are not
likely to cause, prejudice or harm to the grievant, so long as the health care
insurer demonstrates that the violation was for good cause or due to matters
beyond the control of the health care insurer, and that the violation occurred
in the context of an on-going, good faith exchange of information between the
health care insurer and the grievant. This exception is not available if the
violation is part of a pattern or practice of violations by the health care
insurer, as determined by the superintendent.
(2) The grievant may request a written
explanation of the violation from the health care insurer, and the health care
insurer must provide such explanation within 10 days, including a specific
description of its bases, if any, for asserting that the violation should not
cause the internal review process to be deemed exhausted. If an external
reviewer or a court rejects the grievant's request for immediate review on the
basis that the health care insurer met the standards for the exception under
Paragraph (1) of Subsection D of
13.10.17.19 NMAC, the grievant has
the right to re-submit and pursue a request for review of the claim. In such a
case, within a reasonable time after the external reviewer or court rejects the
claim for immediate review (not to exceed 10 days), the health care insurer
shall provide the grievant with notice of the opportunity to re-submit and
pursue the internal review of the claim. Time periods for re-filing the claim
shall begin to run upon grievant's receipt of such notice.
E.
IRO fees. The health care
insurer against which a request for external review has been filed shall be
responsible for paying the fees of the IRO. The health care insurer shall remit
payment to the IRO within 30 days after its receipt of the invoice.
(1) The superintendent shall determine the
reasonable compensation for IROs and shall publish a schedule of IRO
compensation by bulletin.
(2) Upon
completion of the review, the IRO shall submit its invoice directly to the
health care insurer.
F.
In reaching a decision, the assigned IRO is not bound by any decisions or
conclusions reached during the health care insurer's utilization review process
or the health care insurer's internal grievance process.
G. Nothing in this rule shall preclude the
health care insurer and grievant from resolving the matter prior to completion
of the IRO review.
H. A grievant
may not file a subsequent request for external review by an IRO involving the
same adverse determination for which the grievant has already received an
external IRO review under this rule.
Notes
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