N.M. Admin. Code § 8.349.2.9 - COORDINATED SERVICE CONTRACTORS (CSC)
CSCs that manage some services of the medicaid program are responsible for any or all aspects of program management, prior authorization, utilization review, claims processing, and issuance of remittance advices and payments.
A. The CSC shall have a
grievance system in place for recipients that include a grievance process
related to dissatisfaction and an appeals process related to a CSC's action,
including the opportunity to request an HCA fair hearing.
B. A grievance is a recipient's expression of
dissatisfaction about any matter or aspect of the CSC or its operation, other
than a CSC's action, as defined below.
C. An appeal is a request for review by the
CSC of a CSC's action. An action is the denial or limited authorization of a
requested service, including the type or level of service; the reduction,
suspension, or termination of a previously authorized service; the denial, in
whole or in part, of payment for a service; or the failure to provide services
in a timely manner. An untimely service authorization constitutes a denial and
is thus considered an action.
D.
The recipient, legal guardian of the recipient for a minor or an incapacitated
adult, or a representative of the recipient as designated in writing to the
CSC, has the right to file a grievance or an appeal of the CSC's action on
behalf of the recipient. A provider acting on behalf of the recipient, with the
recipient's written consent, may file a grievance or an appeal of a CSC's
action.
E. In addition to the CSC's
grievance and appeal process described above, a recipient, legal guardian of
the recipient for a minor or an incapacitated adult, or the representative of
the recipient has the right to request a fair hearing on behalf of the
recipient with HCA directly as described in 8.352.2 NMAC, Recipient
Hearings, if a CSC's decision results in termination, modification,
suspension, reduction, or denial of services to the recipient or if the
recipient believes the CSC has taken an action erroneously. A fair hearing may
be requested prior to, concurrent with, subsequent to, or in lieu of a
grievance or appeal to the CSC.
Notes
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