New Mexico Administrative Code

A. Provider grievance plan publication and changes. No carrier shall publish a provider grievance plan., or any amendment of a provider grievance plan., that has not been reviewed and approved by the superintendent. A provider grievance plan shall be deemed approved if the superi…

If any section of this rule, or the applicability of any section to any person or circumstance, is for any reason held invalid by a court of competent jurisdiction, the remainder of the rule, or the applicability of such provisions to other persons or circumstances, shall not be …

A. This rule applies to every: (1) health insurance carrier, as defined in Paragraph (2) of Subsection C of Section 59A-16-21.2 NMSA 1978; (2) vision and dental plans that use a provider network; and (3) multiple employer welfare arrangement (individually a "carrier" and collecti…

Sections 59A-16-21.1, 59A-23-14, 59A-46-54, 59A-47-49 and 59A-57-6 NMSA 1978.

Permanent.

January 1, 2023, unless a later date is cited at the end of a section.

The purpose of this rule is to mandate provider grievance processes that are fair, efficient and compliant with all applicable state and federal laws, and to specify practices and procedures for external OSI review of provider grievance appeals.

A. Terms used in this rule are as defined in Section 59A-22B-2 NMSA 1978 and in 13.10.29 NMAC. B. For the purposes of this rule, the subsequent term is supplemented and superseded as follows; "Termination" means the discontinuance of a provider's employment, contractual relations…

A carrier shall adopt and implement a provider grievance plan that complies with this rule. This rule does not preclude a carrier and provider from addressing or resolving a concern through any other process agreed on between them, but no such alternative process shall preclude a…

For a grievance that concerns a termination a provider grievance plan shall also comply with this section. A. Terminations for cause. If a termination for cause, the provider grievance plan shall provide a fair hearing process that provides these minimum rights and protections: (…

Office of Superintendent of Insurance.

A. For covered persons/grievants. A health care insurer shall: (1) include a clear and concise summary of the grievance procedures, both internal and external, in boldface type in all handbooks or evidences of coverage, issued to covered persons, along with a link to the full ver…

The notices required in Subsections A and B, of this section shall be provided to the covered person, the covered person's authorized representative, if applicable, and to a provider or other health care professional with knowledge of the covered person's medical condition. A. Ad…

Upon receipt of a grievance, a health care insurer shall first determine the type of grievance at hand. A. If the grievance seeks review of an adverse determination, it is an adverse determination grievance and the health care insurer shall review the grievance in accordance with…

A. Right to internal review. Every grievant who is dissatisfied with an adverse determination shall have the right to request internal review of the adverse determination by the health care insurer within 180 days of the date of the adverse determination. Nothing in this rule pre…

A. Notice requirements. The health care insurer shall notify the grievant and provider of the decision within 24 hours by telephone and in writing by mail or electronic communication sent within one day after the initial attempt to provide telephonic notice, unless earlier notice…

A. Applicability of internal panel review. (1) A health care insurer that offers managed health care plans shall establish a panel review process for its managed health care plans to give those grievants who are dissatisfied with the internal review decision the option to request…

A. Notice requirements. The health care insurer shall notify the grievant and provider of the internal panel's decision within 24 hours by telephone and in writing by mail or electronic communication sent within one day after the initial attempt to provide telephonic notice, unle…

A. Applicability. This section applies only to entities and grievants subject to the New Mexico Health Care Purchasing Act (public employees and retirees, public school employees and retirees only). B. Eligibility for review. A grievant who remains dissatisfied with the decision …

A. Right to external IRO review. Every grievant who is dissatisfied with an adverse determination following internal review of a grievance that involves medical judgment, including a determination based on medical necessity, appropriateness, health care setting, level of care, ef…

A. Applicability. This rule applies to all health care insurers that provide, offer or administer health benefits plans, including health benefits plans: (1) with a point-of-service option that allows subscribers to obtain health care services out-of-network; (2) provided by an e…

A. Superintendent's list. The superintendent shall compile and maintain a list of approved IROs. B. IRO Requirements. To be considered for placement on the list of approved IROs, an IRO shall: (1) be accredited by a nationally recognized private accrediting entity; (2) meet the r…

A. Expedited IRO review. If required by the medical exigencies of the case, a grievant or provider may telephonically request an expedited review by an IRO by calling the MHCB at (505) 827-4601 or 1-(855)-427-5674. A complaint form with signed medical release must also be provide…

A. Type of IRO review. The IRO shall conduct either a standard or expedited review of the adverse determination, as required by the medical exigencies of the case. (1) The IRO shall complete an expedited external review and provide notice of its decision to the grievant, the prov…

A. Independent decision. In reaching its decision, the IRO is not bound by the prior decision of the health care insurer. In addition to the documents and information provided to the IRO by the health care insurer and the grievant and to the extent such documents are available, e…

A. Grievant's rights. (1) Following the IRO's decision, the MHCB shall notify the grievant that if the grievant is dissatisfied with the IRO's decision, the grievant may request a hearing from the superintendent within 20 days of the IRO decision. MHCB will provide the grievant w…

A. Identification of ICOs. The superintendent shall provide for maintenance of a list of licensed professionals qualified to serve as ICOs. The superintendent shall select appropriate professional societies, organizations or associations to identify licensed health care and other…

A. Deliberation. At the close of the hearing, the hearing officers shall review and consider the entire record and prepare findings of fact, conclusions of law and a recommended decision within 30 days for a standard review. Any hearing officers may submit a supplementary or diss…

A. Request for internal review of administrative decision. Any covered person dissatisfied with an administrative decision, action or inaction of a health care insurer, including termination of coverage, has the right to request internal review of an administrative decision orall…

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 authoriz…

A. Committee Decision. (1) Denial of payment of post-service claim in whole or in part. If the initial administrative decision involved a failure to make payment in whole or in part for a post-service claim for a covered benefit, the reconsideration committee shall review the cla…

Sections 59A-1-16, 59A-2-8, 59A-2-9, 59A-15-16, 59A-16-3, 59A-16-11, 59A-16-12, 59A-16-12.1, 59A-16-20, 59A-16-22, 59A-19-4, 59A-19-6, 59A-22A-7, 59A-46-10, 59A-46-11, 59A-57-1 through 59A-57-11 NMSA 1978.

A. Right to external review and scope. Every grievant who is dissatisfied with the results of the internal review and reconsideration committee hearing of an administrative decision shall have the right to request external review by the superintendent. B. Exhaustion of remedies. …

A. Deadline for filing request. To initiate an external review, a grievant must file a written request for external review with the superintendent within 20 days after receipt of the written notice of the reconsideration committee's decision. The grievant shall file the request f…

A. Acknowledgement. Upon receipt of a completed request for external review, the superintendent shall immediately send: (1) the grievant an acknowledgment that the request has been received; and (2) the health care insurer a copy of the request for external review along with all …

The superintendent shall review the documents submitted by the health care insurer and the grievant, and may conduct an investigation, or inquiry, or consult with the grievant, and the health care insurer, as appropriate. The superintendent shall issue a written decision on the a…

A. Confidentiality Health care insurers, the superintendent, ICOs, IROs and their reviewers, and all others who acquire access to identifiable medical records and information of grievants when reviewing grievances shall treat and maintain such records and information as confident…

A. Record required. The health care insurer shall maintain a grievance register to record all grievances received and handled during the calendar year. The register shall be maintained in a manner that is reasonably clear and accessible to the superintendent. B. Contents. For eac…

Permanent.

January 1, 2017, unless a later date is cited at the end of a section.

The purpose of this rule is to establish procedures for filing and processing adverse determination grievances and administrative grievances regarding actions taken or inaction by a health care insurer.

As used in this rule: A. "Administrative decision" means a decision made by a health care insurer regarding any aspect of a health benefits plan other than an adverse determination, including but not limited to: (1) administrative practices of the health care insurer that affect …

Whenever this rule requires that an action be taken within a certain period of time from receipt of a request or document, the request or document shall be deemed to have been received within three days after the date it was mailed.

A. Written grievance procedures required. Every health care insurer shall establish and maintain separate written procedures that comply with this rule to provide for the internal review of adverse determination grievances and administrative grievances. B. Divisible grievance. If…

New Mexico Public Regulation Commission, Insurance Division.

This rule applies to policies, plans, contracts and certificates that offer maternity benefits delivered or issued for delivery or renewed, extended or amended pursuant to the New Mexico insurance code in this state by any person, insurer, health maintenance organization, fratern…

59A-2-9.4, 59A-22-44, 59A-23-4, 59A-23B-3, 59A-46-45 and 59A-47-33 NMSA 1978.

Permanent.

March 1, 2004 unless a later date is cited at the end of a section.