New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.15 - NOTICE FOLLOWING FIRST LEVEL INTERNAL REVIEW OF ADVERSE DETERMINATIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Notice
				requirements.
The health care insurer shall notify the grievant and
				provider of the decision within 24 hours by telephone and in writing by mail or
				electronic communication sent within one day after the initial attempt to
				provide telephonic notice, unless earlier notice is required by the medical
				exigencies of the case.
B.
Contents of notice.
If the initial decision denying certification
				is upheld in whole or in part, then the health care insurer's notice shall
				include the following:
(1) the name, title
				and qualifying credentials of the person who provided the review;
(2) a statement of the reviewer's
				understanding of the nature of the grievance;
(3) a description of the evidence relied on
				by the reviewer in reaching a decision;
(4) if an adverse determination is upheld
				based on a determination that the requested service is experimental,
				investigational or not medically necessary, then:
(a) clearly and completely explain why the
				requested health care service is not medically necessary, is experimental or
				investigational; a statement that the health care service is not medically
				necessary, is experimental or investigational will not be sufficient;
				and
(b) include a citation to the
				uniform standards relevant to the grievant's medical condition and an
				explanation of whether each standard supported or did not support the
				determination that the requested service is experimental, investigational, or
				is not medically necessary.
(5) if an adverse determination is upheld
				based on a lack of coverage, identify all health benefits plan provisions
				relied on in making the adverse determination, and clearly and completely
				explain why the requested health care service is not covered by any provision
				of the health benefits plan; a statement that the requested health care service
				is not covered by the health benefits plan will not be sufficient;
(6) if the service has already been provided,
				then include the date of service, the provider, the claim amount (if
				applicable), and a statement describing the availability, upon request, of the
				diagnosis code and its corresponding meaning, and the treatment code and its
				corresponding meaning;
(7) notice
				that the grievant may request either:
(a) an
				internal panel review within five days; or
(b) an external review within four
				months.
(8) if the
				adverse determination involves an urgent care situation, advise that the
				grievant may immediately request an expedited IRO external review;
(9) if the grievant is covered by the New
				Mexico Health Care Purchasing Act, then advise the grievant that an internal
				panel review is required before the grievance will be reviewed by the
				grievant's specific review board and only then may the grievant request an
				external review; and
(10) describe
				the procedures and provide all necessary grievance forms to the grievant for
				requesting an internal panel review, for requesting an external review, or for
				requesting an expedited review.