N.M. Admin. Code § 13.10.17.21

Current through Register Vol. 35, No. 24, December 23, 2024

Section 13.10.17.21 - INITIATING AN IRO REVIEW OF AN ADVERSE DETERMINATION:

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 provided. Request for expedited external review filed with the OSI must include a statement from the grievant's treating physician.

B.Standard IRO review. To initiate an IRO review, a grievant must file a written request for an IRO review within four months from receipt of the written notice of the final internal review decision unless extended by the superintendent for good cause shown. The request shall be:

(1) mailed to the superintendent, attention: managed health care bureau - external review request, office of superintendent of insurance, P.O. Box 1689, 1120 Paseo de Peralta, Santa Fe, NM 87504-1689; or

(2) e-mailed to mhcb.grievance@osi.nm.gov, subject: external review request; or

(3) faxed to the superintendent, attention: managed health care bureau - external review request at (505) 827-4253; or

(4) completed on-line with an OSI complaint form available at http://www.osi.state.nm.us.

C.Duty to re-direct request. Any request for external review sent to the health care insurer instead of to OSI shall be forwarded to the OSI by the health care insurer within three days after receipt. Requests for expedited review should be forwarded to OSI as required by the medical exigencies of the case.

D.Documents required to be filed by the grievant. The grievant shall file the request for IRO review on the forms provided to the grievant by the health care insurer, OSI, or an entity that purchases health care benefits pursuant to the New Mexico Health Care Purchasing Act, and shall also file:

(1) a copy of the notice(s) of all prior review decisions; and

(2) a fully executed release form authorizing the IRO or the superintendent to obtain any necessary medical records from the health care insurer or any other relevant provider.

N.M. Admin. Code § 13.10.17.21

Adopted by New Mexico Register, Volume XXVII, Issue 23, December 15, 2016, eff. 1/1/2017, Amended by New Mexico Register, Volume XXXV, Issue 22, November 19, 2024, eff. 11/19/2024