reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.20 - QUALIFICATIONS OF IROs AND APPROVAL BY SUPERINTENDENT

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Superintendent's list.
The
				superintendent shall compile and maintain a list of approved IROs.
B.
IRO Requirements.
To be
				considered for placement on the list of approved IROs, an IRO shall:
(1) be accredited by a nationally recognized
				private accrediting entity;
(2)
				meet the requirements of this rule; and
(3) have quality assurance mechanisms that
				ensure that clinical reviewers assigned to conduct the external review are
				qualified and impartial physicians or other appropriate health care providers
				who;
(a) have expertise in the treatment of
				grievant's medical condition;
(b)
				hold a non-restricted license in a state of the United States and, for
				physicians, a current certification by a recognized medical specialty board in
				the area(s) appropriate to the subject of the IRO review; and
(c) have no history of disciplinary actions
				or sanctions, including loss of staff privileges or participation restrictions,
				that have been taken or are pending by any hospital, governmental agency or
				unit, or regulatory body that raise substantial questions about the clinical
				reviewer's physical, mental or professional competence or moral
				character.
(4) have
				written policies and procedures that ensure:
(a) all reviews are conducted within the
				timeframe specified by this rule and required notices are provided in a timely
				manner;
(b) the selection of
				qualified and impartial physicians or other appropriate health care
				professionals to act as clinical reviewers based on the requirements of
				specific cases and that the IRO employs or contracts with an adequate number of
				clinical reviewers to meet this objective;
(c) the confidentiality of medical and
				treatment records and clinical review criteria; and
(d) that any person employed by or under
				contract with the IRO adheres to the requirements of this rule.
(5) maintain a toll-free telephone
				service to receive information 24 hours a day, seven days per week basis
				related to external reviews that is capable of accepting, recording or
				providing appropriate instruction to incoming telephone callers during other
				than normal business hours.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.21 - INITIATING AN IRO REVIEW OF AN ADVERSE DETERMINATION

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Expedited IRO review.
If
				required by the medical exigencies of the case, a grievant or provider may
				telephonically request an expedited review by an IRO by calling the MHCB at
				(505) 827-4601 or 1-(855)-427-5674. A signed medical release must also be
				provided.
B.
Standard IRO
				review.
To initiate an IRO review, a grievant must file a written
				request for an IRO review within four months from receipt of the written notice
				of the final internal review decision unless extended by the superintendent for
				good cause shown. The request shall be:
(1)
				mailed to the superintendent, attn: managed health care bureau - external
				review request, office of superintendent of insurance, P.O. Box 1689, 1120
				Paseo de Peralta, Santa Fe, NM 87504-1689; or
(2) e-mailed to mhcb.grievance@state.nm.us,
				subject: external review request; or
(3) faxed to the superintendent, attn:
				managed health care bureau - external review request at (505) 827-4734;
				or
(4) completed on-line with an
				OSI complaint form available at
http://www.osi.state.nm.us/
.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.22 - TIMEFRAMES AND PROCESSES FOR IRO REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Type of IRO review.
The IRO
				shall conduct either a standard or expedited review of the adverse
				determination, as required by the medical exigencies of the case.
(1) The IRO shall complete an expedited
				external review and provide notice of its decision to the grievant, the
				provider, the health care insurer, and the superintendent as required by the
				medical exigencies of the case as soon as possible, but in no case later than
				72 hours after appointment by the superintendent. If notice of the IRO's
				decision is initially provided by telephone, written notice of the decision
				shall be provided within 48 hours after the telephone notification.
(2) The IRO shall complete a standard
				external review and provide written notice of its decision to the grievant, the
				provider, the health care insurer and the superintendent within 20 days after
				appointment by the superintendent.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.23 - THE FINAL DECISION OF THE IRO AND GRIEVANT'S RIGHT TO HEARING AFTER FINAL IRO DECISION

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Independent decision.
In reaching its decision, the IRO is not
				bound by the prior decision of the health care insurer. In addition to the
				documents and information provided to the IRO by the health care insurer and
				the grievant and to the extent such documents are available, each reviewer
				shall consider the following in reaching its decision:
(1) the grievant's medical records;
(2) the attending health care professional's
				recommendation;
(3) consulting
				reports from appropriate health care professionals and other documents
				submitted by the health care insurer, the grievant, or the treating health care
				professional;
(4) the terms of
				coverage under the applicable health benefit plan to ensure that the IRO's
				decision is not contrary to the terms of coverage;
(5) the most appropriate practice guidelines,
				which shall include applicable evidence-based standards and may include any
				other practice guidelines developed by the federal government, national or
				professional medical societies, boards and associations;
(6) any applicable clinical review criteria
				and policies developed and used by the health care insurer; and
(7) the opinion of the IRO's clinical
				reviewer(s) after considering the information received.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.24 - SUPERINTENDENT'S HEARING PROCEDURES FOR ADVERSE DETERMINATIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Grievant's rights.
(1) Following the IRO's decision, the MHCB
				shall notify the grievant that if the grievant is dissatisfied with the IRO's
				decision, the grievant may request a hearing from the superintendent within 20
				days of the IRO decision. MHCB will provide the grievant with all forms
				necessary to request a hearing by the superintendent.
(2) Any grievant whose adverse determination
				grievance involved a rescission of coverage or did not involve medical judgment
				may request a hearing by the superintendent within four months of receiving the
				health care insurer's internal decision. The health care insurer will provide
				the grievant will all forms necessary to request a hearing by the
				superintendent.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.25 - INDEPENDENT CO-HEARING OFFICERS (ICOS)

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Identification of ICOs.
The
				superintendent shall provide for maintenance of a list of licensed
				professionals qualified to serve as ICOs. The superintendent shall select
				appropriate professional societies, organizations or associations to identify
				licensed health care and other professionals who are willing to serve as ICOs
				in external reviews who maintain independence and impartiality of the
				process.
B.
Disclosure of
				interests.
Prior to accepting designation as an ICO, each potential ICO
				shall provide to the superintendent a list identifying all health care insurers
				and providers with whom the potential ICO maintains any health care related or
				other professional business arrangements and briefly describe the nature of
				each arrangement. Each potential ICO shall disclose to the superintendent any
				other potential conflict of interest that may arise in hearing a particular
				case, including any personal or professional relationship to the grievant, or
				to the health care insurer, or providers involved in a particular external
				review.
C.
Compensation of
				ICOs.
(1)
Compensation
				schedule.
The superintendent shall determine reasonable compensation for
				health care and other professionals who are appointed as ICOs for external
				grievance reviews and shall annually publish a schedule of ICO compensation in
				a bulletin.
(2)
Statement of
				ICO compensation.
Upon completion of an external review, the attorney
				and co-hearing officers shall each complete a statement of ICO compensation
				form prescribed by the superintendent; detailing the amount of time spent
				participating in the external review, and submit it to the superintendent for
				approval. The superintendent shall send the approved statement of ICO
				compensation to the grievant's health care insurer.
(3)
Direct payment to ICOs.
Within 30 days of receipt of the statement of ICO compensation, the grievant's
				health care insurer shall remit the approved compensation directly to the
				ICO.
(4)
No compensation with
				early settlement.
If the parties provide written notice of a settlement
				up to three days prior to the date set for external review hearing,
				compensation will be unavailable to the hearing officers or ICOs.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.26 - SUPERINTENDENT'S DECISION ON EXTERNAL REVIEW OF ADVERSE DETERMINATION

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Deliberation.
At the close of the hearing, the hearing officers
				shall review and consider the entire record and prepare findings of fact,
				conclusions of law and a recommended decision within 30 days for a standard
				review. Any hearing officers may submit a supplementary or dissenting opinion
				to the recommended decision.
B.
Order.
Within 10 days after receiving the recommendation of the
				ICOs, the superintendent will issue an appropriate order. If the order requires
				action on the part of the health care insurer, the order shall specify the
				timeframe for compliance:
(1) The order shall
				be binding on the grievant and health care insurer and shall state that the
				grievant and the health care insurer have the right to judicial review pursuant
				to Section
				59A-4-20 NMSA
				1978 and that state and federal law may provide other remedies.
(2) Neither the grievant nor the health care
				insurer may file a subsequent request for external review of the same adverse
				determination that was the subject of the superintendent's order.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.27 - INTERNAL REVIEW OF ADMINISTRATIVE GRIEVANCES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Request for internal review of
				administrative decision.
Any covered person dissatisfied with an
				administrative decision, action or inaction of a health care insurer, including
				termination of coverage, has the right to request internal review of an
				administrative decision orally or in writing within 180 days after receiving
				the administrative decision.
B.
Acknowledgement of grievance.
Within three days after receipt of
				an administrative grievance, the health care insurer shall send the grievant a
				written acknowledgment that it has received the administrative grievance. The
				acknowledgment shall contain the name, address and direct telephone number of
				an individual representative of the health care insurer who may be contacted
				regarding the administrative grievance.
C.
Initial review.
The initial
				review shall:
(1) be conducted by a health
				care insurer representative authorized to take corrective action on the
				administrative grievance; and
(2)
				allow the grievant to present any information pertinent to the administrative
				grievance.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.28 - RECONSIDERATION OF INTERNAL REVIEW OF ADMINISTRATIVE GRIEVANCE

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Reconsideration committee.
Upon receipt of a request for
				reconsideration, the health care insurer shall appoint a reconsideration
				committee consisting of two or more representatives of the health care insurer
				who did not participate in the initial decision and who are authorized to take
				corrective action on the grievance.
B.
Hearing.
The reconsideration
				committee shall schedule and hold a hearing within 15 days after receipt of a
				request for reconsideration. The hearing shall be held during regular business
				hours at a location reasonably accessible to the grievant, and the health care
				insurer shall offer the grievant the opportunity to communicate with the
				committee at the health care insurer's expense by conference call, video
				conferencing or other appropriate technology. The health care insurer shall not
				unreasonably deny a request for postponement of the hearing for up to 30 days
				made by a grievant.
C.
Notice.
The health care insurer shall notify the grievant in
				writing of the hearing date, time and place at least five days in advance. The
				notice shall advise the grievant of the rights specified in Subsection E of
				13.10.17.28 NMAC. If the health care insurer will have an attorney represent
				its interests, the notice shall advise the grievant that the health care
				insurer will be represented by an attorney and that the grievant may wish to
				obtain legal representation at grievant's own expense.
D.
Information to grievant.
No
				fewer than three days prior to the hearing, the health care insurer shall
				provide to the grievant all documents and information that the reconsideration
				committee will rely on in reviewing the case.
E.
Rights of grievant.
A
				grievant has the right to:
(1) attend the
				reconsideration committee hearing;
(2) present the grievant's case to the
				reconsideration committee;
(3)
				submit supporting material both before and at the reconsideration committee
				hearing;
(4) ask questions of any
				reconsideration committee member; and
(5) be assisted or represented by a person of
				their choice.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.29 - DECISION OF RECONSIDERATION COMMITTEE

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Committee Decision.
(1)
Denial of payment of post-service
				claim in whole or in part.
If the initial administrative decision
				involved a failure to make payment in whole or in part for a post-service claim
				for a covered benefit, the reconsideration committee shall review the claim to
				determine whether the claim was paid in accordance with the terms of the health
				benefits plan.
(2)
Rescission.
If the initial administrative decision involved
				rescission, the reconsideration committee shall review the request to determine
				whether the grievant or a person seeking coverage on behalf of the grievant
				performed an act, practice or omission that constitutes fraud, or made an
				intentional misrepresentation of material fact, as prohibited by the terms of
				the health benefits plan.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.30 - EXTERNAL REVIEW OF ADMINISTRATIVE GRIEVANCES BY SUPERINTENDENT

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Right to
				external review and scope.
Every grievant who is dissatisfied with the
				results of the internal review and reconsideration committee hearing of an
				administrative decision shall have the right to request external review by the
				superintendent.
B.
Exhaustion
				of remedies.
The superintendent may require the grievant to exhaust any
				grievance procedures adopted by the health care insurer or an entity that
				purchases health care benefits pursuant to the New Mexico Health Care
				Purchasing Act, as appropriate, before accepting a grievance for external
				review.
C.
Deemed
				exhaustion.
If exhaustion of internal reviews is required prior to
				external review, exhaustion must be unnecessary and the internal reviews
				process will be deemed exhausted if:
(1) the
				health care insurer waives the exhaustion requirement; or
(2) the health care insurer is considered to
				have exhausted the internal reviews process by failing to comply with the
				requirements of the internal reviews process.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.31 - REQUIREMENTS FOR EXTERNAL REVIEW OF ADMINISTRATIVE GRIEVANCE

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Deadline
				for filing request.
To initiate an external review, a grievant must file
				a written request for external review with the superintendent within 20 days
				after receipt of the written notice of the reconsideration committee's
				decision. The grievant shall file the request for external review on the forms
				provided by the health care insurer, and submitted as follows:
(1) mailed to the superintendent, attn:
				managed health care bureau - external review request, office of superintendent
				of insurance, P.O. Box 1689, 1120 Paseo de Peralta, Santa Fe, NM
				87504-1689;
(2) e-mailed to
				mhcb.grievance@state.nm.us, subject: external review request;
(3) faxed to the superintendent, attn:
				managed health care bureau - external review request at (505) 827-4734;
				or
(4) completed on-line using an
				OSI complaint form available on website of the OSI.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.32 - ACKNOWLEDGEMENT OF REQUEST FOR EXTERNAL REVIEW OF ADMINISTRATIVE GRIEVANCE BY SUPERINTEDENT

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Acknowledgement.
Upon receipt of a completed request for external
				review, the superintendent shall immediately send:
(1) the grievant an acknowledgment that the
				request has been received; and
(2)
				the health care insurer a copy of the request for external review along with
				all documents submitted by or on behalf of the grievant with the
				request.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.33 - REVIEW OF ADMINISTRATIVE GRIEVANCE BY SUPERINTENDENT

Current through Register Vol. 35, No. 13, July 16, 2024
The superintendent shall review the documents submitted by
				  the health care insurer and the grievant, and may conduct an investigation, or
				  inquiry, or consult with the grievant, and the health care insurer, as
				  appropriate. The superintendent shall issue a written decision on the
				  administrative grievance within 45 days after receipt of the complete request
				  for external review.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.34 - CONFIDENTIALITY OF A GRIEVANT'S RECORDS AND MEDICAL INFORMATION

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Confidentiality
Health care insurers, the superintendent, ICOs,
				IROs and their reviewers, and all others who acquire access to identifiable
				medical records and information of grievants when reviewing grievances shall
				treat and maintain such records and information as confidential except as
				otherwise provided by federal and New Mexico law.
B.
Procedures required.
The
				superintendent, IROs, and health care insurers shall establish procedures to
				ensure the confidential treatment and maintenance of identifiable medical
				records and information of grievants that are submitted as part of any
				grievance.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.35 - RECORD OF GRIEVANCES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Record required.
The health care insurer shall maintain a
				grievance register to record all grievances received and handled during the
				calendar year. The register shall be maintained in a manner that is reasonably
				clear and accessible to the superintendent.
B.
Contents.
For each grievance
				received, the grievance register shall:
(1)
				assign a grievance number;
(2)
				indicate whether the grievance is an adverse determination or administrative
				grievance, or a combination of both;
(3) state the date, and for an expedited
				review, the time the grievance was received;
(4) state the name and address of the
				grievant, if different from the covered person for whom the grievance was
				made;
(5) identify by name and
				member number the covered person making the grievance or for whom the grievance
				was made;
(6) indicate whether the
				grievant's coverage is provided by an entity that purchases or is authorized to
				purchase health care benefits pursuant to the New Mexico Health Care Purchasing
				Act, the medicaid program, or a commercial health care insurer;
(7) identify the health insurance policy
				number and the group if the policy is a group policy;
(8) identify the individual employee of the
				health care insurer to whom the grievance was made;
(9) describe the grievance;
(10) for adverse determination grievances,
				indicate whether the grievance received was an expedited or a standard
				review;
(11) indicate at what level
				the grievance was resolved and what the actual outcome was; and
(12) state the date the grievance was
				resolved and the date the grievant was notified of the outcome.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 18 - MINIMUM COVERAGE FOR TOBACCO CESSATION TREATMENT › Section 13.10.18.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
This rule applies to policies, plans, contracts and
				  certificates that offer maternity benefits delivered or issued for delivery or
				  renewed, extended or amended pursuant to the New Mexico insurance code in this
				  state by any person, insurer, health maintenance organization, fraternal
				  benefit society, nonprofit health care plan, medical insurance pool or health
				  insurance alliance transacting health insurance or providing health care
				  services.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 18 - MINIMUM COVERAGE FOR TOBACCO CESSATION TREATMENT › Section 13.10.18.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
59A-2-9.4, 59A-22-44, 59A-23-4, 59A-23B-3, 59A-46-45 and
				  59A-47-33 NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 18 - MINIMUM COVERAGE FOR TOBACCO CESSATION TREATMENT › Section 13.10.18.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
March 1, 2004 unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 18 - MINIMUM COVERAGE FOR TOBACCO CESSATION TREATMENT › Section 13.10.18.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A. The following
				terms have the meanings given in the cited article or section of the New Mexico
				Statutes Annotated 1978:
(1) Fraternal
				Benefit Society, Section 59A-44-1 NMSA 1978;
(2) Health Insurance Alliance, Section
				59A-56-3 NMSA 1978;
(3) Health
				Maintenance Organization, Section 59A-46-2 NMSA 1978;
(4) Insurer, Section 59A-1-8 NMSA
				1978;
(5) Insurance Code, Section
				59A-1-1 NMSA 1978;
(6) Nonprofit
				Health Care Plan, Chapter 59A, Article 47 NMSA 1978;
(7) New Mexico Medical Insurance Pool,
				Chapter 59A, Article 54 NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 18 - MINIMUM COVERAGE FOR TOBACCO CESSATION TREATMENT › Section 13.10.18.8 - REQUIRED MINIMUM COVERAGE FOR TOBACCO CESSATION TREATMENT

Current through Register Vol. 35, No. 13, July 16, 2024
A. All policies,
				plans, contracts and certificates that offer maternity benefits shall include
				at least the following tobacco cessation treatment benefits, which may be
				subject to deductibles and coinsurance consistent with those imposed on other
				benefits under the same policy, plan, contract or certificate.
(1)
Diagnostic services:
Diagnostic services necessary to identify tobacco use, use-related conditions
				and dependence.
(2)
Pharmacotherapy:
Two 90-day courses of pharmacotherapy per calendar
				year.
(3)
Cessation
				counseling:
A choice of cessation counseling of up to 90 minutes total
				provider contact time or two multi-session group programs per calendar
				year.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 19 - PRESCRIPTION DRUG INFORMATION CARDS › Section 13.10.19.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Applicability.
This rule applies to all health care insurers that
				provide, offer, or administer health benefit plans in New Mexico, except as
				otherwise provided in the act.
B.
Conflicts.
For purposes of this rule, if any provision of this
				rule conflicts with any provision in 13.10.13 NMAC, Managed Health Care, the
				provisions of this rule shall apply.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 19 - PRESCRIPTION DRUG INFORMATION CARDS › Section 13.10.19.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
Act
means the Prescription Drug Uniform
				  Information Card Act, NMSA 1978 Sections 59A-59-1 et seq.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 19 - PRESCRIPTION DRUG INFORMATION CARDS › Section 13.10.19.8 - CONTENT AND FORMAT

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Format.
Prescription drug identification cards shall be printed in Times
				New Roman, font size 8. The information on the front of the card shall be left
				justified; the information on the back of the card shall be centered at the
				bottom of the card.
B.
Additional information.
A health care insurer may add other information
				to a prescription drug identification card as long as the additional
				information does not reduce the readability of the required
				information.
C.
Prior
				approval required.
A health care insurer shall submit to the
				superintendent by March 1, 2004 a schematic showing the contents and format of
				both sides of the card it proposes to use. A health care insurer shall not
				issue prescription drug information cards, or cards for health insurance
				coverage that includes prescription drug coverage, until the superintendent
				approves the contents and format of the card.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 19 - PRESCRIPTION DRUG INFORMATION CARDS › Section 13.10.19.9 - IMPLEMENTATION

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Plan
				required.
A health care insurer shall submit to the superintendent by
				March 1, 2004 an implementation plan detailing how and when the health care
				insurer will meet the requirements of the act and this rule. At a minimum, the
				plan shall indicate when the health care insurer plans to finalize the design
				of the card, when the health care insurer plans to commence issuing approved
				cards, and how the health care insurer plans to have all necessary cards issued
				by July 1, 2005.
B.
Timeframe.
A health care insurer shall issue prescription drug
				information cards that meet the requirements of the act and this rule with new
				policies or renewed policies issued after the superintendent has approved the
				content and format of the card, or as requested by the cardholder, but no later
				than July 1, 2005.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 19 - PRESCRIPTION DRUG INFORMATION CARDS › Section 13.10.19.10 - PENALTIES FOR NONCOMPLIANCE

Current through Register Vol. 35, No. 13, July 16, 2024
The superintendent may impose penalties in accordance with
				  NMSA 1978 Section 59A-1-18 for failure to comply with the requirements of the
				  act and this rule.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 21 - HEALTH CARE SERVICES AND PROVIDER CREDENTIALING REQUIRED FOR HMOs › Section 13.10.21.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
A. Applicability.
				This rule applies to all health care insurers that provide, offer, or
				administer health care coverage pursuant to the health maintenance organization
				(HMO) laws of the state of New Mexico:
B. Exemptions. This rule does not apply to
				policies or certificates that provide coverage for:
(1) only short-term travel, accident-only,
				student health, specified disease, or other limited benefits; or
(2) credit, disability income, hospital
				indemnity, long-term care insurance, vision care or any other limited
				supplemental benefit, including a stand-alone dental benefit plan, whether
				indemnity, PPO, or non-profit plan.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 21 - HEALTH CARE SERVICES AND PROVIDER CREDENTIALING REQUIRED FOR HMOs › Section 13.10.21.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Sections 59A-2-8, 59A-2-9, 59A-4-4, 59A-4-5, 59A-15-16,
				  59A-16-13.1, 59A-22- 41.1, 59A-22-43, 59A-46-2, 59A-46-4, 59A-46-7, 59A-46-23,
				  59A-46-30, 59A-46-35, 59A-46-36, 59A-46-38.2, 59A-46-38.4, 59A-46-38.5,
				  59A-46-39, 59A-46-41, 59A-46-41.1, 59A-46-42, 59A-46-42.2, 59A-46-43,
				  59A-46-43.2, 59A-46-44, 59A-46-45, 59A-46-46, 59A-46-48, 59A-46-49, 59A-57-4,
				  and 59A-57-6 NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 21 - HEALTH CARE SERVICES AND PROVIDER CREDENTIALING REQUIRED FOR HMOs › Section 13.10.21.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
September 1, 2009, unless a later date is cited at the end of
				  a section.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 21 - HEALTH CARE SERVICES AND PROVIDER CREDENTIALING REQUIRED FOR HMOs › Section 13.10.21.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The purpose of this rule is to clarify what is meant by a
				  basic health care plan, for the purposes of certification of a health care plan
				  as a health maintenance organization (HMO), pursuant to the requirements of
				  Section 59A-46-2 NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 21 - HEALTH CARE SERVICES AND PROVIDER CREDENTIALING REQUIRED FOR HMOs › Section 13.10.21.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
In addition to the following, this rule is subject to the
				  definitions found in 13.10.17 NMAC and to the definitions in 59A-46-2 NMSA 1978
				  and 59A-46-7 NMSA 1978.
A.
"Credentialing"
means the process of obtaining and verifying information
				about a health professional and evaluating that health professional when that
				health professional applies to become a participating provider with an
				HMO.
B.
"Credentialing
				intermediary"
means a person to whom an HMO has delegated credentialing
				or recredentialing authority and responsibility.
C.
"Health maintenance organization
				(HMO)"
means any person who undertakes to provide or arrange for the
				delivery of basic health care services to covered persons on a prepaid basis,
				except for covered person responsibility for copayments or
				deductibles.
D.
"Health care
				professional"
means physicians, dentists, registered nurses, licensed
				practical nurses, podiatrists, optometrists, chiropractic physicians, physician
				assistants, nurse anesthetists, certified nurse practitioners, certified
				nurse-midwives, registered lay midwives, clinical psychologists, social
				workers, pharmacists, nutritionists, occupational therapists, physical
				therapists, doctors of oriental medicine, and other professionals engaged in
				the delivery of health care services who are licensed to practice in New
				Mexico, are certified, and are practicing under the authority of an
				HMO.
E.
"Primary care
				practitioner"
means physicians, other health care professionals such as
				doctors of oriental medicine, chiropractic physicians, nurse practitioners,
				physician assistants, or certified nurse midwives who may provide primary care,
				provided that the health care practitioner:
1) is acting within his or her scope of
				practice as defined under the relevant state licensing law;
2) meets the HMO eligibility criteria for
				health care practitioners who provide primary care; and
3) agrees to participate and to comply with
				the health care insurers or HMO care coordination and referral
				policies.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 21 - HEALTH CARE SERVICES AND PROVIDER CREDENTIALING REQUIRED FOR HMOs › Section 13.10.21.8 - HMO BASIC HEALTH CARE SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
A health care insurer offering basic health care services
				  through an HMO shall provide or shall arrange for the following medically
				  necessary basic health care services for its covered persons.
A. An HMO may not provide or arrange to
				provide basic health care services if such services:
(1) do not include all the basic health
				services set forth in this section; or
(2) are limited as to time or cost except as
				prescribed in this section, subject to lifetime policy maximums.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 21 - HEALTH CARE SERVICES AND PROVIDER CREDENTIALING REQUIRED FOR HMOs › Section 13.10.21.10 - PENALTIES

Current through Register Vol. 35, No. 13, July 16, 2024
In addition to any applicable suspension, revocation or
				  refusal to continue any certificate of authority or license under the Insurance
				  Code, a penalty for any material violation of this rule may be imposed against
				  a health care insurer by the superintendent in accordance with Sections
				  59A-1-18, 59A-46-25, and 59A-57-11 NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 21 - HEALTH CARE SERVICES AND PROVIDER CREDENTIALING REQUIRED FOR HMOs › Section 13.10.21.11 - SEVERABILITY

Current through Register Vol. 35, No. 13, July 16, 2024
If any section of this rule, or the applicability of any
				  section to any person or circumstance, is for any reason held invalid by a
				  court of competent jurisdiction, the remainder of the rule, or the
				  applicability of such provisions to other persons or circumstances, shall not
				  be affected.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 22 - MANAGED HEALTH CARE PLAN COMPLIANCE › Section 13.10.22.1 - ISSUING AGENCY

Current through Register Vol. 35, No. 13, July 16, 2024
New Mexico Public Regulation Commission, Division of
				  Insurance, Post Office Box 1269, Santa Fe, New Mexico
				  87504-1269.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 22 - MANAGED HEALTH CARE PLAN COMPLIANCE › Section 13.10.22.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
This rule applies to health care insurers that are required
				  to obtain a certificate of authority or licensure in this state and which
				  provide, offer, or administer managed health care plans. This rule relates to
				  and should be read in conjunction with 13.10.13, 13.10.16, 13.10.17, 13.10.21
				  and 13.10.23 NMAC.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 22 - MANAGED HEALTH CARE PLAN COMPLIANCE › Section 13.10.22.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Sections 59A-1-18, 59A-2-8, 59A-2-9, 59A-4-4, 59A-4-5,
				  59A-15-16, 59A-16-12, 59A-16-12.1, 59A-16-13, 59A-16-22, 59A-18-17,
				  59A-18-27.1, 59A-22-32, 59A-22-32.1, 59A-22A-4, 59A-22A-5, 59A-23-4, 59A-44-34,
				  59A-44-41, 59A-46-7, 59A-46-9, 59A-46-10, 59A-46-11, 59A-46-23, 59A-46-25,
				  59A-46-27, 59A-46-30, 59A-46-35, 59A-46-36, 59A-47-27, 59A-47-29, 59A-47-33,
				  59A-57-2, 59A-57-4, 59A-57-5, 59A-57-6, 59A-57-8, and 59A-57-11 NMSA
				  1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 22 - MANAGED HEALTH CARE PLAN COMPLIANCE › Section 13.10.22.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The purpose of this rule is to ensure the availability,
				  accessibility, and quality of health care services provided by health care
				  insurers through managed health care plans, and to regulate trade practices in
				  the insurance business and related businesses by prohibiting unfair or
				  deceptive acts or practices.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 22 - MANAGED HEALTH CARE PLAN COMPLIANCE › Section 13.10.22.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
In addition to the following, this rule is subject to the
				  definitions found in the Grievance Procedures Rule, 13.10.17 NMAC.
A.
"Claim"
means:
(1) any request by an insured for
				indemnification by a MHCP; and
(2)
				any direct services provided to an individual.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 22 - MANAGED HEALTH CARE PLAN COMPLIANCE › Section 13.10.22.9 - UTILIZATION MANAGEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				Utilization management program: The health care insurer through its MHCP shall
				establish and implement a comprehensive utilization management program to
				monitor access to and appropriate utilization of health care services. The
				program shall be under the direction of a medical director responsible for the
				medical services provided by the MHCP in New Mexico and who is a licensed
				physician in New Mexico, and shall be based on a written plan that is reviewed
				at least annually. At a minimum, the plan shall identify the following:
(1) scope of utilization management
				activities;
(2) procedures to
				evaluate clinical necessity, access, appropriateness, and efficiency of
				services;
(3) mechanisms to detect
				underutilization and overutilization;
(4) clinical review criteria and protocols
				used in decision-making;
(5)
				mechanisms to ensure consistent application of review criteria and uniform
				decisions;
(6) development of
				outcome and process measures for evaluating the utilization management program;
				and
(7) a mechanism to evaluate
				member and provider satisfaction with the complaint and appeals systems set
				forth at 13.10.17 NMAC; such evaluation shall be coordinated with the
				performance monitoring activities conducted pursuant to the continuous quality
				improvement program to include care coordination between utilization
				management, case management and disease management services as set forth in
				13.10.22.10 NMAC.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 22 - MANAGED HEALTH CARE PLAN COMPLIANCE › Section 13.10.22.10 - CONTINUOUS QUALITY IMPROVEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				Under the direction of a medical director or his or her designated physician,
				the MHCP shall have a system-wide continuous quality improvement program to
				monitor the quality and appropriateness of care and services provided to
				covered persons. This program shall be based on a written plan which is
				reviewed at least annually and revised as necessary. The plan shall describe at
				least:
(1) the scope and purpose of the
				program;
(2) the organizational
				structure of quality improvement activities;
(3) duties and responsibilities of the
				medical director and/or designated physician responsible for continuous quality
				improvement activities;
(4)
				contractual arrangements, where appropriate, for delegation of quality
				improvement activities;
(5)
				confidentiality policies and procedures;
(6) specification of standards of care,
				criteria and procedures for the assessment of the quality of services provided
				and the adequacy and appropriateness of health care resources
				utilized;
(7) a system of ongoing
				evaluation activities, including individual case reviews as well as pattern
				analysis;
(8) a system of focused
				evaluation activities, particularly for frequently performed and/or highly
				specialized procedures;
(9) a
				system for monitoring random covered person satisfaction and network provider's
				response and feedback on MHCP operations;
(10) a system for verification of providers'
				credentials, recertification, performance reviews and for obtaining information
				about any disciplinary action against a provider available from any state
				licensing board applicable to the provider;
(11) the procedures for conducting peer
				review activities, which shall include providers within the same discipline and
				area of clinical practice;
(12) a
				system for evaluation of the effectiveness of the continuous quality
				improvement program to include care coordination between utilization
				management, case management and disease management services.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 22 - MANAGED HEALTH CARE PLAN COMPLIANCE › Section 13.10.22.11 - CULTURAL AND LINGUISTIC DIVERSITY

Current through Register Vol. 35, No. 13, July 16, 2024
The MHCP must ensure that information and services are
				  available in languages other than English, that services are provided in a
				  manner that takes into account cultural aspects of the covered person
				  population, and that accommodations are provided for covered persons with
				  disabilities. Each MHCP shall develop, implement, and maintain a plan that
				  reasonably addresses the cultural and linguistic diversity of its covered
				  person population.
A. MHCPs that have
				not already done so and are currently doing business in New Mexico shall submit
				to the superintendent for approval a plan of how the MHCP will address the
				cultural and linguistic diversity of its covered person population. At a
				minimum, the plan shall address:
(1) how the
				MHCP will identify the language needs of covered persons;
(2) measures to be taken to ensure access for
				limited-English-proficient (LEP) covered persons in both administrative and
				health care encounters with the plan and its providers;
(3) steps the MHCP will take to ensure
				availability of adequate interpretation services within its network, which
				shall include a description of specific contracts or other arrangements for
				interpretation and identification of interpreters for the deaf;
(4) whether interpreting services are
				available to covered persons on a 24-hour basis for emergency care;
(5) whether linguistic and cultural needs are
				explicitly addressed in the MHCP's continuous quality improvement
				program;
(6) how the MHCP will
				conduct outreach to ensure that covered persons with particular cultural and
				linguistic needs are identified by the MHCP and made aware of the services
				available to them to address their needs;
(7) any guidelines or training regarding
				cultural and linguistic needs of covered persons that the MHCP will utilize
				with its own staff and providers within its network;
(8) the extent to which the MHCP contracts
				with community clinics and other local providers that offer linguistic and
				culturally appropriate services to covered persons in their areas;
				and
(9) physical accessibility to
				persons with disabilities of MHCP information and administrative services as
				well as the provider network.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 22 - MANAGED HEALTH CARE PLAN COMPLIANCE › Section 13.10.22.13 - ADMINISTRATIVE COSTS AND BENEFIT DISCLOSURES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Yearly reporting required:
On a yearly basis, on or before April 15, each MHCP shall provide the
				superintendent with a loss ratio for individual contracts and a separate
				calculation for plans offered in the small group health insurance market by the
				MHCP. The superintendent may require that the information be prepared on a form
				supplied by the division.
B.
Calculation of the ratio:
Calculation of the loss ratio shall be based
				on the average of a plan's previous three years' experience. The superintendent
				shall apply or alter this calculation in a manner consistent with New Mexico
				law.
(1) If the plan has been in existence
				for less than three years, than the ratio shall be based on a two year past
				plan experience, with a statement as to the length of plan
				experience.
(2) If the plan has
				been in existence for less than two years, than the ratio shall be based on a
				one year past plan experience, with a statement as to the length of plan
				experience.
(3) If the plan is new
				or has been in existence less than one year, then the MHCP shall report to the
				superintendent a loss ratio for a similar plan with an explanation as to why
				that plan can be used as an estimated loss ratio for the new plan.
(4) The superintendent shall state on any
				materials distributed to the public the bases for the loss ratios.
(5) The superintendent shall provide notice
				to brokers, agents, and solicitors engaged in the sale of managed health care
				plans regarding the availability and use of the loss ratios for
				MHCPs.
(6) The superintendent may
				in the future require in addition to the ratio calculations, that each MHCP
				provide the division with sample premium costs for various plan designs, to be
				used by the superintendent as a guide to purchasing managed health care
				products in the state.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 22 - MANAGED HEALTH CARE PLAN COMPLIANCE › Section 13.10.22.14 - PENALTIES

Current through Register Vol. 35, No. 13, July 16, 2024
In addition to any applicable suspension, revocation or
				  refusal to continue any certificate of authority or license under the Insurance
				  Code, a penalty for any material violation of this rule may be imposed against
				  a health care insurer by the superintendent in accordance with Sections
				  59A-1-18 and 59A-46-25 NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 22 - MANAGED HEALTH CARE PLAN COMPLIANCE › Section 13.10.22.15 - SEVERABILITY

Current through Register Vol. 35, No. 13, July 16, 2024
If any section of this rule, or the applicability of any
				  section to any person or circumstance, is for any reason held invalid by a
				  court of competent jurisdiction, the remainder of the rule, or the
				  applicability of such provisions to other persons or circumstances, shall not
				  be affected.