N.M. Admin. Code § 13.10.17.28 - RECONSIDERATION OF INTERNAL REVIEW OF ADMINISTRATIVE GRIEVANCE
A.
Reconsideration committee. Upon receipt of a request for
reconsideration, the health care insurer shall appoint a reconsideration
committee consisting of two or more representatives of the health care insurer
who did not participate in the initial decision and who are authorized to take
corrective action on the grievance.
B.
Hearing. The reconsideration
committee shall schedule and hold a hearing within 15 days after receipt of a
request for reconsideration. The hearing shall be held during regular business
hours at a location reasonably accessible to the grievant, and the health care
insurer shall offer the grievant the opportunity to communicate with the
committee at the health care insurer's expense by conference call, video
conferencing or other appropriate technology. The health care insurer shall not
unreasonably deny a request for postponement of the hearing for up to 30 days
made by a grievant.
C.
Notice. The health care insurer shall notify the grievant in
writing of the hearing date, time and place at least five days in advance. The
notice shall advise the grievant of the rights specified in Subsection E of
13.10.17.28 NMAC. If the health
care insurer will have an attorney represent its interests, the notice shall
advise the grievant that the health care insurer will be represented by an
attorney and that the grievant may wish to obtain legal representation at
grievant's own expense.
D.
Information to grievant. No fewer than three days prior to the
hearing, the health care insurer shall provide to the grievant all documents
and information that the reconsideration committee will rely on in reviewing
the case.
E.
Rights of
grievant. A grievant has the right to:
(1) attend the reconsideration committee
hearing;
(2) present the grievant's
case to the reconsideration committee;
(3) submit supporting material both before
and at the reconsideration committee hearing;
(4) ask questions of any reconsideration
committee member; and
(5) be
assisted or represented by a person of their choice.
Notes
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