N.M. Admin. Code § 8.354.2.16

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

Section 8.354.2.16 - HSD ADMINISTRATIVE HEARING FINAL DECISION

The final decision concerning the HSD administrative hearing is made by the MAD director or designee after the review of the HSD administrative hearing record and the ALJ's recommendation. If the ALJ had rendered a decision to dismiss a HSD administrative hearing request, that decision becomes the HSD administrative hearing final decision and the following process detailed in this section of the rule does not apply.

A.Decision based on the record: The ALJ's HSD administrative hearing recommendation must be based solely on the record of the HSD administrative hearing.

B.ALJ recommendation: The ALJ shall review the record of the HSD administrative hearing and submit a complete copy of the record to the MAD director.

(1) Content of the ALJ recommendation: the ALJ shall specify the reasons for his or her conclusions, identifies the supporting evidence, references the pertinent federal and state statutes, regulations, and NMAC rules, and responds to the arguments of the parties within his or her written report.

(2) The ALJ recommends:

(a) in favor of the claimant if MAD, its UR contractor, the MCO or their designee's intended or taken adverse action is not supported by a preponderance of the evidence submitted during the HSD administrative hearing; the ALJ will provide specific recommendations to each appealed adverse action;

(b) in favor of MAD, if the preponderance of evidence submitted during the HSD administrative hearing supports the intended or taken of adverse action or actions; or

(c) any other result supported by the record of the HSD administrative hearing which may be a combination of recommendations for and against the claimant or MAD; if the HSD administrative hearing covered a number of services or components of a service, the ALJ will provide specific recommendations to each intended or taken adverse action.

C.Review of the record: The record of the HSD administrative hearing and the report and recommendation of the ALJ is reviewed by the MAD director or designee to ensure conformity with applicable federal and state statutes, regulations, and rules.

D.Final decision: The ALJ's recommendation may be adopted or rejected in a final written decision by the MAD director or designee on issues that were the subject of the HSD administrative hearing. The MAD director's final decision letter shall specify the reasons for his or her decision and identify the regulatory authority and those portions of the record, applicable federal and state law, rules and policies or any combination of these that support the final decision. No person who participated during the HSD administrative hearing process may participate in arriving at a HSD administrative hearing final decision.

E.Notice to parties: MAD shall promptly provide all parties with a copy of the HSD administrative hearing final written decision. When the claimant is represented by legal counsel or an authorized representative, each must receive a copy of the final decision. The HSD administrative hearing final decision letter shall include an explanation that the parties have exhausted all HSD administrative remedies and a claimant or the claimant's authorized representative may pursue judicial review of this decision.

N.M. Admin. Code § 8.354.2.16

8.354.2.156 NMAC - Rp, 8.354.2.14 NMAC, 8/1/14