N.M. Admin. Code § 8.308.15.13

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

Section 8.308.15.13 - MCO EXPEDITED MEMBER APPEAL PROCESS

The MCO shall establish and maintain an expedited review process for a MCO expedited member appeal when the MCO, the member or his or her authorized representative or authorized provider believes that allowing the time for a standard member appeal resolution could seriously jeopardize the member's life, health, or his or her ability to attain, maintain, or regain maximum function. Once a member or his or her authorized representative or authorized provider requests a MCO expedited member appeal and the member or his or her authorized representative or authorized provider requests a continuation of the member's disputed current benefit, the MCO will grant a continuation of the disputed current benefit until the MCO expedited member appeal final decision is rendered by the MCO. However, if the date of the MCO expedited member appeal final decision letter is prior to the notice of action's adverse action effective date, the MCO must continue the disputed current benefit up to the adverse action's effective date. The MCO shall ensure that health care professionals with appropriate clinical expertise in addressing the physical health, behavioral health, or long-term services and supports needs of the member are utilized during the MCO expedited member appeal process when the MCO notice of action for the disputed benefit is based on a lack of medical necessity.

A. A member or his or her authorized representative or authorized provider in accordance with the member's MCO procedures has the right to request within 60 calendar days after the mailing of the MCO's notice of action a MCO expedited member appeal orally or in writing. When the mailing date of the notice of action is disputed or there is a discrepancy between the mailing date and the postmarked date, the postmarked date will prevail.

(1) If a member, his or her authorized representative or authorized provider elects to request a continuation of the member's disputed current benefit, the member or his or her authorized representative or authorized provider must request a MCO expedited member appeal and request a continuation of the member's disputed current benefit within 10 calendar days of the mailing of the MCO's notice of action. When the mailing date of the notice of action is disputed or there is a discrepancy between the mailing date and the postmarked date, the postmarked date will prevail. The continuation of the disputed current benefits is not dependent on the approval to proceed to the MCO expedited appeal process. See 8.308.15.15 NMAC for a detailed description of the continuation of the disputed benefit process.

(2) If the member or authorized representative or authorized provider requests a MCO expedited member appeal, the following applies.

(a) If the member or his or her authorized representative designate in writing the member's provider to act as the member's authorized provider, the authorized provider may request a MCO expedited member appeal when the authorized provider believes that the MCO has made an incorrect decision concerning the member's disputed benefit.

(b) If the MCO upholds its adverse action, regardless of who requested the MCO expedited member appeal process, the MCO expedited 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 the member's disputed benefit.

(c) Once the member or his or her authorized representative request a HSD expedited or standard administrative hearing, he or she is referred to as the claimant.

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

(5) The member or his or her authorized representative or the authorized provider does not have the right to request a MCO expedited or standard member appeal or a HSD expedited or standard administrative hearing related to a value-added service offered by the MCO.

(6) 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.

B. The request for a MCO expedited member appeal may be made orally or in writing to the member's MCO within the required time frame. The reasons why a MCO expedited member appeal is necessary must be detailed in the oral or written request. A member's provider (regardless if the provider is not the authorized provider) may assist the member or his or her authorized representative in stating the reasons and providing supporting documentation that a MCO expedited member appeal is medically necessary. There can only be one MCO member appeal request concerning the disputed benefit at one time. If the MCO denies the request for a MCO expedited member appeal, the member or his or her authorized representative may then request a HSD expedited or standard administrative hearing regarding the issue of the denial of a MCO expedited member appeal. See 8.352.2 NMAC for a detailed description of the HSD expedited and standard administrative hearing processes.

C. The MCO shall designate a specific employee as its MCO expedited member appeal manager with the authority to:

(1) administer the policies and procedures for resolution of a MCO expedited member appeal;

(2) review patterns and trends in member expedited appeals and initiate corrective action; and

(3) ensure there is no punitive or retaliatory action taken against any member, his or her authorized representative or authorized provider that files an expedited MCO member appeal, or a provider that supports the member's appeal.

D. The MCO shall provide reasonable assistance to the member or his or her authorized representative or the authorized provider requesting a MCO expedited member appeal in completing forms and completing procedural steps, including but not limited to:

(1) providing interpreter services;

(2) providing toll-free numbers that have adequate TTY/TTD and interpreter capability; and

(3) assisting the member, his or her authorized representative or the authorized provider in understanding the MCO rationale regarding the disputed benefit which was wholly denied, partially denied or that was limited in order to ensure that the issue under expedited appeal is sufficiently defined throughout the MCO expedited member appeal.

E. The MCO shall provide in writing to the member, his or her authorized representative, and the member's provider (regardless if the provider is not the authorized provider) with the following information once a request is made for a MCO expedited member appeal:

(1) the date the MCO expedited member appeal request was received by the MCO, and the MCO's understanding of what the member or his or her authorized representative or the authorized provider is appealing concerning the member's disputed benefit;

(2) the expected date of the MCO member appeal decision:

(a) that is not to exceed 72 hours from the date of the receipt of the request for a MCO expedited member appeal; and

(b) that alerts the member or his or her authorized representative or the authorized provider of the possibility of an appeal extension of up to an additional 14 calendar days when:

(i) the member or his or her authorized representative or authorized provider requests the extension; or

(ii) the MCO determines it requires additional information and provides a written justification to the member or his or her authorized representative or authorized provider, and also places in the member's MCO expedited member appeal file how the extension is in the best interest of the member.

F.Time frames:

(1) The MCO must act as expeditiously as the member's condition requires, but no later than 72 hours after receipt of a request for a MCO expedited member appeal, and provide the member and his or her authorized representative and the authorized provider its MCO expedited member appeal final decision. The MCO must also make reasonable efforts to provide oral notice of the decision.

(2) If the member or his or her authorized representative or the authorized provider requests an extension of the decision date, the MCO shall extend the 72-hour time period up to 14 calendar days to allow the member or his or her authorized representative or the authorized provider to submit additional documentation to the MCO supporting the need for the MCO expedited member appeal.

(3) The MCO may itself extend the 72-hour time period when it determines there is a need to collect and review additional information prior to rendering its MCO expedited member appeal final decision. The MCO must provide justification in writing to the member or his or her authorized representative or the authorized provider and also place in the member's expedited member appeal file how the extension of time is in the member's best interest.

(4) A member or his or her authorized representative may file a MCO member grievance against the MCO's decision to extend the 72-hour time frame and up to an additional 14 calendar days.

G.MCO-initiated expedited MCO member appeal: When the MCO determines that allowing the time for a standard MCO member appeal process could seriously jeopardize the member's life, health, or his or her ability to attain, maintain, or regain maximum function, the MCO shall:

(1) automatically file a MCO-initiated expedited member appeal on behalf of the member and continue the disputed current benefit without cost to the member if the MCO-initiated expedited member appeal final decision upholds the MCO adverse action;

(2) make reasonable efforts to provide the member, his or her authorized representative and the member's provider (regardless if the provider is not the authorized provider) prompt oral notice of the automatic appeal, following up as expeditious as possible, but within 72 hours of the MCO expedited member appeal final decision; and

(3) use its best effort to involve the member, his or her authorized representative and the member's provider (regardless if the provider is not the authorized provider) in the member's MCO-initiated expedited member appeal. The member's MCO expedited appeal record will contain the dates, times, and methods the MCO utilized to contact the member, his or her authorized representative or the authorized provider, or another provider of the member. If the MCO-initiated member appeal final decision upholds the MCO's adverse action, the MCO member appeal process is exhausted and the member or his or her authorized representative may request a HSD expedited or standard administrative hearing.

N.M. Admin. Code § 8.308.15.13

8.308.15.13 NMAC - Rp, 8.308.15.10 NMAC, 6-15-14, Adopted by New Mexico Register, Volume XXIX, Issue 08, April 24, 2018, eff. 5/1/2018