N.M. Admin. Code § 8.354.2.18

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

Section 8.354.2.18 - IMPLEMENTATION OF THE HSD ADMINISTRATIVE FINAL DECISION

The HSD administrative hearing final decision is binding on all issues that have been the subject of the HSD administrative hearing as to the claimant unless stayed by either a court order or by the MAD director or designee. MAD is responsible for ensuring that the HSD administrative hearing final decision is fulfilled.

A. If the claimant is a member and he or she received a benefit under his or her approved continuation of the benefit and the decision is favorable to the MCO, the claimant's MCO will not take action to file a repayment claim to the claimant or the claimant's authorized representative for the services received during the MCO appeal and the HSD administrative hearing process up to the date of the HSD administrative hearing final decision.

B. If the claimant is not enrolled in an MCO and the HSD administrative hearing final decision is favorable to MAD, its UR contractor or designee, MAD will not take action to file a repayment claim to the claimant or the claimant's authorized representative for the services received during the HSD administrative hearing process up to the date of the HSD administrative hearing final decision.

C. When the HSD administrative hearing final decision is favorable to the claimant, MAD, its UR contractor, the MCO or their designee will authorize the benefit and coverage set forth in the HSD administrative hearing final decision.

N.M. Admin. Code § 8.354.2.18

8.354.2.19 NMAC - Rp, 8.354.2.16 NMAC, 8/1/14