N.M. Admin. Code § 8.349.2.10 - GENERAL REQUIREMENTS FOR GRIEVANCE AND APPEALS
A. The CSC shall implement written policies
and procedures describing how the recipient may submit a request for a
grievance or an appeal with the CSC or submit a request for a fair hearing with
the HCA. The policy shall include a description of how the CSC resolves the
grievance or appeal.
B. The CSC
shall provide to all service providers and subcontractors in the CSC's network
a written description of the CSC's grievance and appeal process and how the
provider can submit a grievance or appeal.
C. The CSC shall have available reasonable
assistance in completing forms and taking other procedural steps. This
includes, but is not limited to, providing interpreter services and toll-free
numbers that have adequate TTY/TTD and interpreter capability.
D. The CSC shall name a specific
individual(s) designated as the CSC's medicaid recipient grievance coordinator
with the HCA to administer the policies and procedures for resolution of a
grievance or an appeal, to review patterns/trends in grievances or appeals, and
to initiate corrective action.
E.
The CSC shall ensure that the individuals that make the decisions on grievances
or appeals are not involved in any previous level of review or decision-making.
The CSC shall also ensure that health care professionals with appropriate
clinical expertise shall make decisions for the following:
(1) an appeal of a CSC denial that is based
on lack of medical necessity;
(2) a
CSC denial that is upheld in an expedited resolution;
(3) a grievance or appeal that involves
clinical issues.
F. Upon
enrollment, the CSC shall provide recipients, at no cost, with an information
sheet or handbook that provides information on how they or their
representative(s) can file a grievance or an appeal, and the resolution
process. The recipient information shall also advise recipients of their right
to file a request for an administrative hearing with the HCA hearings bureau,
upon notification of a CSC action, or concurrent with or following an appeal of
the CSC action.
G. The CSC shall
ensure that punitive or retaliatory action is not taken against a recipient or
a provider that files a grievance or an appeal, or a provider that supports a
recipients' grievance or appeal.
Notes
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