N.M. Admin. Code § 8.308.15.14

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

Section 8.308.15.14 - MCO STANDARD MEMBER APPEAL PROCESS

A. A member or his or her authorized representative or the 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 standard member appeal orally and 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. If orally requested, the request must be followed up in writing within 13 calendar days of the oral request.

(1) If a member or 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 the authorized provider must request a MCO standard 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. See 8.308.15.15 NMAC for a detailed description of the continuation of the disputed current benefit process.

(2) If the member or his or her authorized representative or the authorized provider requests a MCO standard member appeal, the following apply.

(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 standard 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 standard member appeal process, the MCO 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 the member's disputed benefit.

(c) If a member or his or her authorized representative elects not to request a HSD expedited or standard administrative hearing, and if the date of the MCO standard 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 notice of action's adverse action effective date.

(d) 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.

(3) 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 standard member appeal process.

(4) 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.

(5) 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 or standard administrative hearing processes.

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

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

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

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

C. The MCO shall provide reasonable assistance to the member or his or her authorized representative or the authorized provider requesting a MCO standard 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 or 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 that the issue under appeal is sufficiently defined throughout the MCO standard member appeal.

D. The MCO shall provide the member or 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 standard member appeal.

(1) The date the MCO standard 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 standard member appeal decision:

(a) that is not to exceed 30 calendar days from the date of the receipt of the request for a MCO standard 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 to the member or his or her authorized representative or authorized provider, and also places in the member's MCO standard member appeal file how the extension is in the best interest of the member.

E. Time frames:

(1) The MCO must act as expeditiously as the member's condition requires, but no later than 30 calendar days after receipt of a request for a MCO standard member appeal, and provide the member or his or her authorized representative or the authorized provider its MCO standard member appeal final 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 30 calendar day time period up to an additional 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 medical necessity for the disputed benefit.

(3) The MCO may itself extend the final decision up to the additional 14 calendar day time period when it determines there is a need to collect and review additional information prior to rendering its MCO standard 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 clinical 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 appeal or grievance against the MCO's decision to extend the 30 calendar day time frame up to an additional 14 calendar days.

N.M. Admin. Code § 8.308.15.14

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