N.M. Admin. Code § 8.354.2.7 - DEFINITIONS

A. "Administrative law judge (ALJ)" means the HSD fair hearings bureau's (FHB) appointed judge to oversee the claimant's administrative hearing process and render a recommendation to the medical assistance division (MAD) director.

B. "Adverse action": means:

(1) the belief of a claimant or his or her authorized representative that his or her preadmission or annual resident review (PASRR) determination is erroneous; or

(2) the belief of a claimant or his or her authorized representative that the claimant's NF determination to transfer or discharge him or her is erroneous.

C. "Authorized representative" means the individual designated to represent and act on the claimant's behalf during the appeal process. The claimant or the claimant's authorized representative must provide formal documentation authorizing the named individual or individuals to access the indentified case information for a specified purpose and time frame. An authorized representative may be an attorney representing a person or household, a person acting under the authority of a valid power of attorney, a guardian, or any other individual or individuals designated in writing by the claimant.

D. "Claimant" means the individual requesting a HSD administrative hearing that is claiming to be affected by an adverse action or actions taken or intended to be taken by MAD, its utilization review (UR) contractor, the MCO or their designees.

E. "Denial" means the decision not to authorize the medical assistance program (MAP) eligible recipient or a MCO member's requested services, item, or level of care (LOC).

F. "Designee" means a state agency or an institution MAD has designated to be responsible for:

(1) conducting a PASRR level I screening to identify if a MAP eligible recipient or a MCO member has a mental illness or an intellectual disability; or

(2) conducting a PASRR level II evaluation.

G. "DOH-DDSD" means the developmental disabilities support division of the department of health, which conducts the PASRR level II evaluation for a MAP eligible recipient or a MCO member that has been identified through a PASRR level I screen.

H. "HSD administrative hearing" or "fair hearing" means an informal evidentiary hearing that is conducted by the FHB so that evidence may be presented as it relates to an adverse action taken, or intended to be taken, by MAD, it UR contractor, or the MCO, or their designees.

I. "MAD" means the medical assistance division, which administers medicaid and other medical assistance programs under HSD.

J. "MAP" means the medical assistance programs administered by MAD.

K. "MCO" means a member's HSD contracted managed care organization.

L. "Member" means a MAP eligible recipient enrolled in a HSD contracted MCO. Once a member requests a HSD administrative hearing, the member is referred to as a claimant.

M. "Notice of action" means the notice issued by MAD, its UR contractor, the MCO or their designees of their intent to take an adverse action against eligible recipient or a member in the form an adverse determination is made with regard to the preadmission or annual resident review requirements or a discharge or transfer from a NF.

N. "Nursing facility (NF)" means a MAD enrolled, and as appropriate, a MCO contracted, NF which meets the requirements as described in 8.312.2 NMAC and is designated by MAD, its UR contractor, or the MCO to complete a PASRR level I screen for a MAP eligible recipient or a MCO member.

O. "Parties to the hearing" are MAD, its UR contractor, the MCO or their designees and the claimant or his or her authorized representative.

Notes

N.M. Admin. Code § 8.354.2.7

8.354.2.7 NMAC - Rp, 8.354.2.7 NMAC, 8/1/14