New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 15 - GRIEVANCES AND APPEALS › Section 8.308.15.14 - MCO STANDARD MEMBER APPEAL PROCESS

Current through Register Vol. 35, No. 13, July 16, 2024
A. A member or his or her authorized
				representative or the authorized provider in accordance with the member's MCO
				procedures has the right to request within 60 calendar days after the mailing
				of the MCO's notice of action a MCO standard member appeal orally and in
				writing. When the mailing date of the notice of action is disputed or there is
				a discrepancy between the mailing date and the postmarked date, the postmarked
				date will prevail. If orally requested, the request must be followed up in
				writing within 13 calendar days of the oral request.
(1) If a member or his or her authorized
				representative or authorized provider elects to request a continuation of the
				member's disputed current benefit, the member or his or her authorized
				representative or the authorized provider must request a MCO standard member
				appeal and request a continuation of the member's disputed current benefit
				within 10 calendar days of the mailing of the MCO's notice of action. When the
				mailing date of the notice of action is disputed or there is a discrepancy
				between the mailing date and the postmarked date, the postmarked date will
				prevail. See
				8.308.15.15
				NMAC for a detailed description of the continuation of the disputed current
				benefit process.
(2) If the member
				or his or her authorized representative or the authorized provider requests a
				MCO standard member appeal, the following apply.
(a) If the member or his or her authorized
				representative designate in writing the member's provider to act as the
				member's authorized provider, the authorized provider may request a MCO
				standard member appeal when the authorized provider believes that the MCO has
				made an incorrect decision concerning the member's disputed benefit.
(b) If the MCO upholds its adverse action,
				regardless of who requested the MCO standard member appeal process, the MCO
				standard member appeal process is considered exhausted and the member or his or
				her authorized representative may request a HSD expedited or standard
				administrative hearing concerning the member's disputed benefit.
(c) If a member or his or her authorized
				representative elects not to request a HSD expedited or standard administrative
				hearing, and if the date of the MCO standard member appeal final decision
				letter is prior to the notice of action's adverse action effective date, the
				MCO must continue the disputed current benefit up to the notice of action's
				adverse action effective date.
(d)
				Once the member or his or her authorized representative requests a HSD
				expedited or standard administrative hearing, he or she is referred to as the
				claimant.
(3) The member
				or his or her authorized representative or the authorized provider may have
				legal counsel or a spokesperson assist him or her during the MCO standard
				member appeal process.
(4) The
				member or his or her authorized representative or the authorized provider does
				not have the right to request a MCO expedited or standard member appeal or a
				HSD expedited or standard administrative hearing related to a value-added
				service offered by the MCO.
(5) The
				authorized provider is not eligible to request a HSD expedited or standard
				administrative hearing on the disputed benefit, unless the provider has been
				designated as the member's authorized representative. See 8.352.2 NMAC for a
				detailed description of the HSD expedited or standard administrative hearing
				processes.