New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 2 - PROVIDER NETWORK › Section 8.308.2.11 - STANDARDS FOR ACCESS

Current through Register Vol. 35, No. 13, July 16, 2024
The MCO shall establish and follow protocols to ensure the
				  accessibility, availability and referral to health care providers for each
				  medically necessary service to its members. The MCO shall provide access to the
				  full array of covered services within the benefit package. If a service is
				  unavailable based on the access guidelines, a service equal to or higher than
				  that service shall be offered.
A.
				Access to urgent and emergency services: Services for emergency conditions
				provided by physical and behavioral health providers, including emergency
				transportation, urgent conditions, and post-stabilization care shall be covered
				by the MCO (only within the United States for both physical and behavioral
				health). An urgent condition exists when a member manifests acute symptoms and
				signs that, by reasonable medical judgment, represent a condition of sufficient
				severity that the absence of medical attention within 24 hours could reasonably
				result in an emergency condition. Serious impairment of biopsychosocial
				functioning, imminent out-of-home placement for child and adolescent members or
				serious jeopardy to the behavioral health of the member are considered urgent
				conditions. An emergency condition exists when a member manifests acute
				symptoms and signs that, by reasonable lay person judgment, represent a
				condition of sufficient severity that the absence of immediate medical
				attention, including behavioral health treatment, could reasonably result in
				death, serious impairment of bodily function or major organ or serious jeopardy
				to the overall health of the member or with respect to a pregnant woman, the
				health of the woman or her unborn child, in serious jeopardy.
				Post-stabilization care means covered services related to an emergency medical
				or behavioral health condition, that are provided after the member is
				stabilized in order to maintain the stabilized condition and may include
				improving or resolving the member's condition.
(1) The MCO shall ensure that there is no
				clinically significant delay caused by the MCO's utilization control measures.
				Prior authorization is not required for emergency services in or out of the
				MCO's network, and all emergency services shall be reimbursed at the HSD
				approved rate. The MCO shall not retroactively deny a claim for an emergency
				screening examination because the condition, which appeared to be an emergency
				medical or behavioral health condition under the prudent layperson standard,
				turned out to be non-emergent in nature.
(2) The MCO shall ensure that the member has
				the right to use any hospital or other licensed emergency setting for emergency
				care, regardless of whether the provider is contracted with the MCO.
(3) The MCO shall ensure that the member has
				access to the nearest appropriately designated trauma center according to
				established emergency medical standards (EMS) triage and transportation
				protocols.