N.M. Admin. Code § 8.308.15.10 - MCO PROVIDER APPEALS

A. Upon a provider contracting with the MCO, the MCO shall provide at no cost a written description of its provider appeal policies and procedures and instructions on how to act as a member's authorized provider to the provider. The MCO will update in writing each of its providers with any changes to these policies and procedures. The MCO will additionally provide to a non-contracted provider who is seeking to or has rendered services or items to the MCO's member, policies and procedures informing the provider of his or her rights and responsibilities to be designated by a member or the member's authorized representative to act as his or her authorized provider, and how to request a MCO expedited or standard member appeal as the authorized provider.

(1) The description shall include:

(a) information on how the provider can file a MCO provider appeal and the resolution process;

(b) time frames for each step of the MCO provider appeal process through its final resolution; and

(c) a description of how the provider's MCO appeal is resolved.

(2)The MCO shall designate a specific employee as its provider appeal manager with the authority to:

(a) administer the policies, procedures and processes for a resolution of an appeal;

(b) review patterns and trends in appeals and initiate corrective action; and

(c) ensure that punitive or retaliatory action is not taken against any provider that files a MCO provider appeal.

B. Standing to request a MCO provider appeal: A provider or its authorized representative may request a MCO provider appeal for an intended or taken adverse action against a provider based on the MCO denial of the provider's payment, including a denial of a claim for lack of medical necessity or as not a covered benefit.

C. Provider rights and limitations:

(1) A provider or representative may request a MCO provider appeal either orally or in writing in accordance with the MCO's policies and procedures.

(2)A provider or his or her authorized representative may have its legal counsel or a spokesperson be a party to the MCO provider appeal process.

(3) If the MCO upholds its adverse action in the MCO's provider appeal final decision, the appeal process will be considered exhausted. The provider is not eligible to request a HSD provider administrative hearing. The loss of the appeal does not make the member liable for any payment to the provider.

Notes

N.M. Admin. Code § 8.308.15.10

8.308.15.10 NMAC - Rp, 8.308.15.10 NMAC, 6-15-14, Adopted by New Mexico Register, Volume XXIX, Issue 08, April 24, 2018, eff. 5/1/2018