New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 352 - ADMINISTRATIVE HEARINGS › Part 2 - CLAIMANT HEARINGS › Section 8.352.2.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A. "Administrative
				law judge (ALJ)" means the hearing officer appointed by the HSD fair hearings
				bureau (FHB) to oversee the claimant's administrative hearing process, to
				produce and evidentiary record and render a recommendation to the medical
				assistance division director.
B.
				"Appeal" means the process open to a managed care organization's member when
				his or her managed care organization (MCO) has taken, or intends to take, an
				adverse action related to the member's benefits or services.
C. "Authorized representative" means the
				individual designated to represent and act on the claimant's behalf during the
				appeal process. The claimant or authorized representative must provide formal
				documentation authorizing the named individual or individuals to access the
				identified case information for a specified purpose and time frame. An
				authorized representative may be an attorney representing a person or
				household, a person acting under the authority of a valid power of attorney, a
				guardian, or any other individual or individuals designated in writing by the
				claimant.
D. "Claimant" means the
				individual, or in case of eligibility determinations, the household, requesting
				a HSD administrative hearing that is claiming to be affected by an adverse
				action or actions taken or intended to be taken by MAD, its UR contractor or a
				MCO.
E. "HSD administrative
				hearing" or "fair hearing" means an informal evidentiary hearing that is
				conducted by the FHB so that evidence may be presented as it relates to an
				adverse action taken, or intended to be taken, by MAD, its UR contractor, or
				the MCO; see Section 10 of this rule for definitions of an adverse
				action.
F. "MAD" means the medical
				assistance division, which administers medicaid and other medical assistance
				programs under HSD.
G. "MAP" means
				the medical assistance programs administered by MAD.
H. "MCO" means a member's HSD contracted
				managed care organization.
I. "MCO
				appeal decision" means the MCO's final decision regarding a member's appealed
				adverse action it intends to take or has taken against its member.
J. "Member" means a MAP eligible recipient
				enrolled in a HSD contracted MCO.
K. "Notice of action" means the notice issued
				by MAD or its UR contractor or a MCO. Adverse actions include:
(1) the intent of MAD or its UR contractor or
				the MCO to take an adverse action against an individual in the form of a
				termination, suspension, change or reduction, of an existing service including
				level of care (LOC) or the transfer or discharge of a nursing facility (NF)
				resident. If the notice of action is for one of the listed adverse actions, MAD
				or its UR contractor or the MCO must send the notice of action 10 calendar days
				prior to the date of the intended adverse action; or
(2) an adverse determination made with regard
				to preadmission or annual resident review (PASRR) requirements; or
(3) the denial or reduction, or a limited
				authorization of a service including the type or level of care of a request for
				a new service or item.