N.M. Admin. Code § 8.308.15.16

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

Section 8.308.15.16 - MCO EXPEDITED MEMBER APPEAL AND MCO STANDARD MEMBER APPEAL FINAL DECISION AND IMPLEMENTATION

A. The MCO shall provide the member or his or her authorized representative and the provider (regardless if the provider was not the one requesting the MCO member appeal) with its MCO expedited or standard member appeal final decision within the required time frames and provide supporting documentation substantiating the MCO's decision.

B. When the MCO expedited or standard member appeal final decision reverses the MCO's adverse action in total and the disputed benefit was not furnished during the member's expedited or standard member appeal process, the MCO shall authorize or provide the disputed benefit promptly and as expeditiously as the member's health condition requires.

C. When the MCO expedited or standard member appeal final decision reverses the MCO's adverse action in total and the member, his or her authorized representative or authorized provider had requested and the member had received a continuation of the disputed current benefit during the MCO expedited or standard member appeal process, the MCO may not recover from the member the cost of the continued disputed current benefit furnished during the MCO expedited or standard member appeal process.

D. When the MCO expedited or standard member appeal final decision upholds the MCO's adverse action and the member or his or her authorized representative or authorized provider had requested and the member had received a continuation of the disputed current benefit, the MCO may recover from the member the cost of the disputed current benefit furnished during the MCO expedited or standard member appeal process if:

(1) the member, his or her authorized representative or authorized provider was informed in writing by the MCO that the member could be responsible for the cost of the disputed current benefit if the MCO expedited or standard member appeal final decision upholds the MCO adverse action; and

(2) the member or his or her authorized representative elects not to request a HSD expedited or standard administrative hearing of the disputed current benefit.

(3) A MCO cannot recover the cost of the continued disputed benefit regardless if the final decision is upheld or reverses the MCO adverse action when the MCO initiated the MCO expedited member appeal process. See Subsection E of 8.308.15.13 NMAC for detailed description of a MCO-initiated expedited member appeal process.

E. A member or his or her authorized representative may request a HSD expedited or standard administrative hearing if the MCO expedited or standard member appeal decision does not reverse in total the MCO's adverse action as the member or his or her authorized representative has now exhausted the MCO expedited or standard member appeal process. The authorized provider cannot request a HSD expedited or standard administrative hearing on his or her own; this right is accorded only to the member or his or her authorized representative, unless the provider has been designated as the member's authorized representative.

F. A member or his or her authorized representative must request a HSD expedited administrative hearing within 30 calendar days of the date of the MCO member appeal final decision letter or request a HSD standard administrative hearing within 90 days of the date of the MCO member appeal final decision.

(1) A member or his or her authorized representative or authorized provider may request and the member receive a continuation of the disputed current benefit at any time prior to the MCO notice of action's intended date the disputed benefit will be terminated. The request may be made even after the MCO expedited or standard member appeal final decision letter is issued if issued before the date the disputed benefit will be terminated.

(2) If the member received a continuation of his or her disputed current benefit during the MCO member appeal process, the member or his or her authorized representative does not need to request another continuation of the disputed current benefit when requesting a HSD expedited or standard administrative hearing. It is automatically continued by the member's MCO.

(3) If the member or his or her authorized representative chooses to discontinue the disputed current benefit that is being provided during the MCO expedited or standard member appeal process or during the HSD expedited or standard administrative hearing process, the member or his or her authorized representative must notify the member's MCO in writing stating the date the disputed current benefit will end.

G. When the MCO expedited or standard member appeal final decision upholds the MCO's adverse action in total or in part and the member or his or her authorized representative or authorized provider had requested and the member had received the disputed current benefit during the MCO member appeal, and the member or his or her authorized representative elects to continue the member's disputed current benefit during the member's HSD expedited or standard administrative hearing process, the MCO must in writing inform the member or his or her authorized representative that if the HSD expedited or standard administrative hearing final decision upholds the MCO's adverse action, the member could be responsible for the cost of the disputed current benefit during MCO expedited or standard member appeal process and the HSD expedited or standard administrative hearing process.

H. If the member or his or her authorized representative requests a HSD expedited or standard administrative hearing and the member or his or her authorized representative or authorized provider requested and the member received the disputed current benefit during the MCO member appeal process, the MCO will not take action to recover the costs of the continued disputed current benefit until there is a HSD expedited or standard administrative hearing final decision upholding the MCO adverse action.

I. If the member's MCO had automatically filed a MCO-initiated expedited member appeal on behalf of the member to continue the disputed current benefit during the MCO expedited member appeal process, the MCO cannot take action to recover the costs of the continued disputed current benefit if the MCO expedited member appeal final decision upholds the MCO's adverse action. However, if the member or his or her authorized representative wants to continue the disputed current benefit during the HSD expedited or standard administrative hearing, the member could be responsible for the cost of the continued disputed current benefit starting on the first calendar day the member or the authorized representative requested a HSD expedited or standard administrative hearing and requested the continuation of the disputed current benefit.

J. See 8.352.2 NMAC for a detailed description of the HSD expedited and standard administrative hearing processes and for a detailed description of the MCO recovery process.

N.M. Admin. Code § 8.308.15.16

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