N.M. Admin. Code § 8.308.15.15

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

Section 8.308.15.15 - CONTINUATION OF A DISPUTED CURRENT BENEFIT DURING THE MCO EXPEDITED AND STANDARD MEMBER APPEAL PROCESSES

A member or his or her authorized representative or authorized provider requesting a MCO expedited or standard member appeal of an adverse action may request that the disputed current benefit continue during the MCO expedited or standard member appeal process. However, if the date of the MCO expedited or standard member appeal final decision letter is prior to the effective date of 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.

A. A request for a continuation of the disputed current benefit shall be accorded to any member who or through the member's authorized representative or authorized provider requests the continuation of the disputed current benefit who also requests a MCO expedited or standard member appeal within 10 calendar days of the mailing of the notice of action or prior to the date the notice of action states the benefit will be terminated. 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.

B. The continuation of a disputed current benefit is only available to a member who is currently receiving the disputed benefit at the time of the MCO's notice of action.

(1) The continuation of the disputed current benefit is the same as the member's current benefit, which includes the member's current allocation, budget or LOC.

(2) The MCO must provide written information in its notice of action of the member's or his or her authorized representative's or authorized provider's rights and responsibilities to continue the disputed current benefit during the MCO expedited or standard member appeal process and of the possible responsibility of the member to repay the MCO for the disputed current benefit if the MCO expedited or standard member appeal final decision upholds the MCO's adverse action. If it was a MCO-initiated expedited member appeal, the MCO cannot recover the cost of the disputed current benefit if the MCO's adverse action is upheld.

C. A member or his or her authorized representative or authorized provider has the right to not request a continuation of the disputed current benefit during the MCO expedited or standard member appeal process.

N.M. Admin. Code § 8.308.15.15

8.308.15.15 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