N.M. Admin. Code § 8.308.15.11

Current through Register Vol. 35, No. 23, December 10, 2024

Section 8.308.15.11 - GENERAL INFORMATION ON MCO MEMBER GRIEVANCES AND APPEALS PROCESSES

A. Upon a member's enrollment:

(1) the MCO shall provide to the member and his or her authorized representative at no cost a written description of its member grievance and member expedited and standard appeal system and member expedited appeal system procedures and processes;

(2) the MCO will promptly provide in writing to each member, his or her authorized representative any changes to these procedures and processes. The description shall include:

(a) information on how the member or his or her authorized representative or authorized provider can request a MCO expedited or standard appeal, or how the member or his or her authorized representative can file a MCO member grievance; and the resolution processes for each;

(b) time frames for each step of the MCO member grievance and the MCO expedited and standard member appeal processes through to their final resolution;

(c) a description of how a MCO member's grievance or MCO expedited or standard member appeal is resolved;

(d) information that the MCO may have only one level of appeal for the member;

(e) in the case of a MCO that fails to adhere to the time frames for each step of its procedures and process, the member or his or her authorized representative is deemed to have exhausted the MCO's expedited or standard member appeal process and the member or his authorized representative may request a HSD expedited or standard administrative hearing.

(f) The MCO shall designate a specific employee as its member grievance and appeal manager with the authority to:

(i) administer the policies and procedures for resolution of a MCO member grievance and a MCO expedited or standard member appeal;

(ii) review patterns and trends in MCO member grievances, and MCO expedited or standard member appeals; and

(iii) ensure that punitive or retaliatory action is not taken against any member or his or her authorized representative that files a MCO member grievance or any member, his or her authorized representative or the authorized provider who requests a MCO expedited or standard member appeal.

(g) Prior to the MCO taking an adverse action, in order to avoid incomplete information during the MCO expedited or standard member appeal process or the HSD expedited or standard administrative hearing process, the MCO must contact the requesting provider for more information or justification regarding the request if lack of information or justification is likely to lead to the adverse action.

B. MCO member grievance and MCO expedited and standard member appeal rights and responsibilities:

(1)Standing to file a MCO member grievance:

(a)The member or his or her authorized representative may file a MCO member grievance concerning dissatisfaction with the MCO's operation.

(b) The member or his or her authorized representative may choose a relative, friend or other spokesperson to advocate or assist him or her through the MCO member grievance process; however, the spokesperson is limited to a supporting role and cannot act on behalf of the member or his or her authorized representative. The member or his or her authorized representative must provide the MCO a signed release-of-information in order for the designated spokesperson to have access to information to aid the spokesperson to assist or advocate for the member or his or her authorized representative during the MCO's member grievance process. A member or his or her authorized representative may elect not to sign such a release, but utilize the spokesperson during the MCO member grievance process.

(2) The member or his or her authorized representative may have legal counsel assist him or her during the MCO member grievance process.

(3) Grievance: A member or his or her authorized representative shall have the right to file a grievance with his or her MCO to express dissatisfaction about any matter or aspect of his or her MCO's operation other than an adverse benefit determination without time limitations. A MCO member grievance final decision cannot be appealed through the MCO member appeal process or the HSD administrative hearing process. If the member or his or her authorized representative or the authorized provider wishes to appeal an intended or taken adverse action against the member, the member, his or her authorized or the authorized provider must comply with all requirements to request a MCO expedited or standard member appeal including applicable time frames in which to request a MCO expedited or standard member appeal. A member may file both a MCO member grievance and a MCO expedited or standard member appeal, but the MCO appeal must meet all applicable filing time requirements which are not changed by the filing of a grievance.

(a) The member or his or her authorized representative may file a MCO member grievance either orally or in writing in accordance with the MCO's procedures and processes.

(b) The member or his or her authorized representative may file a MCO member grievance at any time when he or she wishes to register his or her dissatisfaction.

(c) The MCO will provide the member or his or her authorized representative with its resolution to the member's grievance within the time frame specified in the MCO's medicaid managed care services agreement.

(4)MCO expedited or standard member appeal: A member or his or her authorized representative or the authorized provider has the right to request a MCO standard member appeal orally and in writing in accordance with his or her MCO procedures within 60 calendar days of the date of notice of an intended or taken adverse action. If the request is orally, it must be followed up in writing within 13 calendar days of the oral request. A member, his or her authorized representative or authorized provider has the right to request a MCO expedited member appeal orally or in writing in accordance with the member's MCO procedures within 60 calendar days of the date of the notice of an intended or taken adverse action.

(a) The member or his or her authorized representative or the authorized provider may have legal counsel to assist him or her during the MCO expedited or standard member appeal process.

(b) Standing to request a MCO expedited or standard member appeal:

(i)The member or his or her authorized representative may request a MCO expedited or standard member appeal concerning his or her disputed benefit.

(ii) The member, his or her authorized representative or authorized provider may choose a relative, friend or other spokesperson to advocate or assist him or her through the MCO expedited or standard member appeal process; however, the spokesperson is limited to a supporting role and cannot act on behalf of the member or his or her authorized representative. The member or his or her authorized representative must provide the MCO a signed release-of-information in order for a designated spokesperson to have access to information to aid the spokesperson to assist and advocate for the member or his or her authorized representative during the MCO expedited or standard member appeal process.

(c) If a member or his or her authorized representative or authorized provider elects to request a continuation of the disputed current benefit, the member, his or her authorized representative or authorized provider must request a MCO expedited or standard member appeal and also request a continuation of the disputed benefit within 10 calendar days of the mailing of the MCO's notice of action or before the expected effective date of the MCO's proposed adverse action benefit determination, whichever is later. When the mailing date is disputed or there is a discrepancy between the mailing date and the postmarked date, the postmarked date will prevail. The member or his or her authorized representative or authorized provider does not have the right to request a HSD expedited or standard administrative hearing related to a value-added services offered by the MCO. If the member or his or her authorized representative or authorized provider chooses to request a MCO expedited or standard member appeal, the following apply.

(i) The member, his or her authorized representative or authorized provider cannot request separate appeals. Only one appeal can be filed.

(ii) If the MCO upholds its adverse action, regardless of who requested the MCO expedited or standard member appeal, the MCO expedited or standard member appeal process is considered exhausted and the member or his or her authorized representative may request a HSD expedited or standard administrative hearing concerning his or her disputed benefit. Once the member or his or her authorized representative requests a HSD expedited or standard administrative hearing, he or she is referred to as the claimant. The authorized provider is not eligible to request a HSD expedited or standard administrative hearing on the disputed benefit, unless the provider has been designated as the member's authorized representative. See 8.352.2 NMAC for a detailed description of the HSD expedited and standard administrative hearing processes.

N.M. Admin. Code § 8.308.15.11

8.308.15.11 NMAC - Rp, 8.308.15.11 NMAC, 6-15-14, Adopted by New Mexico Register, Volume XXIX, Issue 08, April 24, 2018, eff. 5/1/2018