reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 351 - SANCTIONS OR REMEDIES › Part 2 - SANCTIONS AND REMEDIES › Section 8.351.2.13 - RECOVERY OF OVERPAYMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
MAD can seek recovery of overpayments through the recoupment
				  or repayment process. Overpayments are amounts paid to a MAD provider or other
				  entity in excess of the MAD allowable amount. Overpayment amounts must be
				  collected within 24 months of the initiation of recovery. Overpayment includes,
				  but is not limited to, payment for any claim for which the provider or other
				  entity was not entitled to payment because an applicable MAD NMAC rule and its
				  requirements were not followed. Payment made to a pharmacy for a controlled
				  substance or another prescribed drug item for which the prescriber did not
				  follow all state and federal regulations, laws or rules may be subject to
				  recoupment from the prescriber or entity to which the prescriber is associated.
				  Recovery of overpayments through a HSD contracted MCO is also subject to the
				  provisions of 8.308.22 NMAC.
A.
Auditing procedures:
(1) Prima
				facie evidence: The audit findings generated through the audit procedure shall
				constitute prima facie evidence in all MAD proceedings of the number and amount
				of requests for payment as submitted by the provider or other entity.
(2) Use of statistical sampling techniques:
				MAD's procedures for auditing a provider or other entity may include the use of
				random sampling and extrapolation. When this procedure is used, all sampling
				will be performed using generally accepted statistical methods and will yield
				statistically significant results at a confidence level of at least 90 percent.
				Findings of the sample will be extrapolated to the universe for the audit
				period.
(3) Burden of proof: When
				MAD's final audit findings have been generated through the use of sampling and
				extrapolation, and the provider or other entity disagrees with the findings
				based on the sampling and extrapolation methodology that was used, the burden
				of proof of compliance rests with the provider or other entity. The provider or
				other entity may present evidence to show that the sample was invalid. The
				evidence must include a 100 percent audit of the universe of provider records
				used by MAD in the drawing of its sample. Any such audit must:
(a) be arranged and paid for by the provider
				or other entity;
(b) be conducted
				by a certified public accountant;
(c) demonstrate that a statistically
				significantly higher number of claims and records not reviewed in MAD sample
				were in compliance with MAD NMAC rules, and
(d) be submitted to MAD with all supporting
				documentation.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 351 - SANCTIONS OR REMEDIES › Part 2 - SANCTIONS AND REMEDIES › Section 8.351.2.14 - NOTICE REQUIREMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Content of provider notice:
With the exception of a referral based
				on a credible allegation of fraud, as that term is defined in federal statute
				or regulation or both, when MAD seeks overpayment recovery, or to impose
				sanctions or remedies, written notice is sent to the provider or other entity.
				The notice sent to a non-nursing facility provider or other entity contains the
				following information:
(1) nature of the
				violation or misconduct;
(2) dollar
				value, if applicable, the method, criteria or both used for determining the
				overpayment, intended sanction, or amount of civil monetary penalty to be
				imposed;
(3) provider's right to a
				HSD provider administrative hearing, the right to be represented by counsel at
				the hearing proceeding, and the process necessary to request a HSD provider
				administrative hearing.
(4)
				statement notifying the provider that if he or she does not request a HSD
				provider administrative hearing, the action proposed by MAD will be deemed
				final for purposes of collection of overpayment and imposition of sanctions;
				and
(5) a statement that provider
				has 30 calendar days from the date of the notice to request a HSD provider
				administrative hearing.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 351 - SANCTIONS OR REMEDIES › Part 2 - SANCTIONS AND REMEDIES › Section 8.351.2.15 - REQUEST FOR PROVIDER HEARING

Current through Register Vol. 35, No. 13, July 16, 2024
A provider can request a hearing if he or she disagrees with
				  any of the aforementioned actions taken or sanctions or remedies imposed by
				  MAD, as applicable. Requests for a HSD provider administrative hearing must be
				  made within 30 calendar days or within the time limit specified on the notice
				  of MAD action. A NF or ICF-IID provider must submit the request to DOH within
				  60 calendar days of the notice of the proposed imposition of remedies related
				  to noncompliance with certification or licensing requirements. If a provider
				  fails to request a HSD provider administrative hearing during this time frame,
				  the provider waives its right to an appeal. See 8.352.3 NMAC for information on
				  the MAD provider administrative hearing process and a provider rights and
				  responsibilities.
A.
Imposition
				of remedies:
MAD can impose all remedies on a MAD enrolled provider
				after notifying the provider in a timely manner of the deficiencies an
				impending sanction, or remedy. Except for the imposition of civil monetary
				penalties against a NF provider, imposition of sanctions for violation of the
				Medicaid Provider Act and referrals based on credible allegations of fraud, any
				applicable sanctions or remedy may be imposed prior to the HSD provider
				administrative hearing.
B.
Stay granted:
As applicable, the provider can request that the
				imposition of sanctions or remedies be stayed while the HSD provider
				administrative hearing process is pending by submitting such request in writing
				to MAD. Granting of a stay is at the discretion of the MAD director upon
				consideration of health service available and other related concerns. Interest
				on civil money penalties or overpayments accrues from the date of the initial
				determination.
C.
Collection
				of civil monetary penalties for noncompliance:
MAD may not collect a
				civil money penalty against a NF provider until a final decision is made that
				supports the imposition of the penalty. In instances where imposition of civil
				money penalties are proposed due to noncompliance with certification
				requirements, a NF provider may waive its right to a HSD provider
				administrative hearing by submitting a written request to DOH. Waiver of the
				right to such a hearing reduces the amount of the specified penalty by 35
				percent. A NF provider may submit a plan of correction or request a resurvey
				without prejudicing its position during the hearing.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 352 - ADMINISTRATIVE HEARINGS › Part 2 - CLAIMANT HEARINGS › Section 8.352.2.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program and other health care
				  programs are administered pursuant to regulations promulgated by the federal
				  department of health and human services under Title XIX of the Social Security
				  Act as amended or by state statute. See Section 27-1-12 et seq NMSA 1978.
				  Section 9-8-1 et seq. NMSA 1978 establishes the health care authority (HCA) as
				  a single, unified department to administer laws and exercise functions relating
				  to health care facility licensure and health care purchasing and
				  regulation.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 352 - ADMINISTRATIVE HEARINGS › Part 2 - CLAIMANT HEARINGS › Section 8.352.2.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of this rule is to provide instruction for the
				  service portion of the New Mexico medical assistance
				  programs.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 352 - ADMINISTRATIVE HEARINGS › Part 2 - CLAIMANT HEARINGS › Section 8.352.2.8 - MISSION STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
To reduce the impact of poverty on people living in New
				  Mexico by providing support services that help families break the cycle of
				  dependency on public assistance.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 352 - ADMINISTRATIVE HEARINGS › Part 2 - CLAIMANT HEARINGS › Section 8.352.2.9 - CLAIMANT OR THE CLAIMANT'S AUTHORIZED REPRESENTATIVE AND HSD ADMINISTRATIVE HEARING PROCESS

Current through Register Vol. 35, No. 13, July 16, 2024
MAD has established a process to determine if an individual
				  is eligible to request a HSD administrative hearing. MAD has also established a
				  process for an individual or the individual's authorized representative to
				  request a HSD administrative hearing when an adverse action is intended or has
				  been taken by MAD, its UR contractor or the MCO against the individual; see
				  Section 10 of this rule.
A. Eligible
				claimant:
(1) When an adverse eligibility
				determination is made by HSD against a MAP applicant, he or she may file as a
				claimant to request a HSD administrative hearing. See 8.100.970 NMAC for the
				rules governing a HSD administrative hearing for a MAP adverse eligibility
				determination.
(2) When an adverse
				action is taken or intended to be taken against a MAP eligible recipient by MAD
				or its UR contractor, the MAP eligible recipient may file as a claimant to
				request a HSD administrative hearing.
(3) When an adverse action is taken or
				intended to be taken against a member by his or her MCO, and the member has
				exhausted his or her MCO's appeal process, he or she may file as a claimant to
				request a HSD administrative hearing.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 352 - ADMINISTRATIVE HEARINGS › Part 2 - CLAIMANT HEARINGS › Section 8.352.2.10 - ADVERSE ACTION

Current through Register Vol. 35, No. 13, July 16, 2024
The following constitute an adverse action for which an
				  individual may request a MCO appeal and a HSD administrative hearing.
A. The denial or reduction by MAD, its UR
				contractor, or a MCO of an authorized service or item, including level of care
				(with the exception of a MCO value-added service).
B. When a notice of action against a member
				is not from his or her MCO, but instead is from an entity MAD has authorized to
				make utilization of service determinations, the member may request a HSD
				administrative hearing rather than request a MCO appeal.
C. The denial in whole or in part of an
				individual's provider claim by MAD, its UR contractor, or the MCO which results
				in the individual becoming liable for payment of all or part of the claim when
				the denial is based on medical necessity.
D. The failure of MAD, its UR contractor or
				the MCO to approve a service or item in a timely manner.
E. The failure of the MCO to act on an appeal
				within the time-frames specified in
				42 CFR Section
				438.408(b).
F. The MCO's final decision to deny a member
				a MCO expedited appeal hearing. The HSD administrative hearing will only
				address the member's request for a MCO expedited appeal hearing.
G. The denial of an individual's application
				for MAP enrollment.
H. A
				determination that an individual is to be transferred or discharged.
I. The belief of an individual or the
				individual's authorized representative that the MAD UR contractor or the MCO's
				preadmission, change in condition, or annual resident review (PASRR)
				requirements determination is erroneous. When a claimant requests a HSD
				administrative hearing due to an adverse PASRR determination, the parties to
				the hearing will comply with 8.354.2 NMAC in place of this rule.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 352 - ADMINISTRATIVE HEARINGS › Part 2 - CLAIMANT HEARINGS › Section 8.352.2.11 - RIGHT TO A HSD ADMINISTRATIVE HEARING

Current through Register Vol. 35, No. 13, July 16, 2024
MAD must grant an individual or his or her authorized
				  representative the opportunity for a HSD administrative hearing under specific
				  circumstances pursuant to
				  42 CFR Section
				  431.220(a) and 27 - 3 - 3
				  NMSA 1978. A HSD administrative hearing occurs telephonically between the
				  parties to the hearing and the assigned ALJ.
A. An individual or the individual's
				authorized representative may request a HSD administrative hearing based on his
				or her belief that MAD or its UR contractor intends to take, or has taken, an
				adverse action.
B. A member shall
				have the right to request a HSD administrative hearing after he or she has
				exhausted the MCO's appeal process and:
(1)
				the member does not agree with the MCO's final decision;
(2) the member requests an HSD administrative
				hearing within 30 calendar days of the date of the MCO's final decision;
				and
(3) the basis for the member's
				request for an HSD administrative hearing meets one of the definitions of an
				adverse action in Section 10 of this rule.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 352 - ADMINISTRATIVE HEARINGS › Part 2 - CLAIMANT HEARINGS › Section 8.352.2.12 - NOTICE, TIME LIMITS, POSTPONEMENT, OR THE DISMISSAL OF MCO APPEAL OR A HSD ADMINISTRATIVE HEARING REQUEST

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Notice:
(1) MAD or its UR contractor shall issue a
				"notice of action" to an individual when it intends to take an adverse action
				against an individual. When the notice of action relates to a reduction or
				termination of a service, LOC, or another benefit the individual already
				receives, the notice of action shall be sent not less than 10 calendar days
				prior to the date of MAD's or its UR contractor's intended adverse
				action.
(2) The MCO appeal process
				is governed by and set forth in detail in 8.308.15 NMAC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 352 - ADMINISTRATIVE HEARINGS › Part 2 - CLAIMANT HEARINGS › Section 8.352.2.13 - SCHEDULING OF A HSD ADMINISTRATIVE HEARING

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Scheduling:
The ALJ will
				assign a date for a HSD administrative hearing that affords the MAD director
				the opportunity to render his or her HSD administrative hearing final decision
				within the 90 calendar day time limit. The claimant or the claimant's
				authorized representative must agree via a recorded message to the assigned ALJ
				or in writing to the assigned ALJ to extend the 90 calendar day time limit up
				to an additional 30 calendar days to provide the necessary time for the HSD
				administrative hearing to be conducted and a final decision rendered. The ALJ
				has the authority on a case-by-case basis to extent the 90-calendar day time
				limit to more than 30-calendar days when the claimant or the claimant's
				authorized representative requests such an extension in writing. If an
				accommodation is necessary for a disability, the claimant or the claimant's
				authorized representative must notify FHB at least 10 calendar days prior to
				the HSD administrative hearing.
B.
Rescheduling:
Any party to a HSD administrative hearing may
				request, and is entitled to receive, one postponement of a HSD administrative
				hearing, as long as it does not interfere with the HSD administrative hearing
				final decision time frames.
(1) A request for
				more than one postponement is at the ALJ's discretion on a case-by-case
				basis.
(2) The claimant or the
				claimant's authorized representative must agree to allow the ALJ to extend the
				90 calendar day time limit up to an additional 30 calendar days to provide the
				necessary time for the HSD administrative hearing to be conducted and a final
				decision rendered.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 352 - ADMINISTRATIVE HEARINGS › Part 2 - CLAIMANT HEARINGS › Section 8.352.2.14 - SUMMARY OF EVIDENCE (SOE)

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Summary of evidence.
(1) At a
				HSD administrative hearing, MAD has the burden to prove through the
				preponderance of the evidence that an adverse action against a claimant is
				correct. A summary of evidence (SOE) provides information concerning the basis
				of MAD, its UR contractor or the MCO's adverse action. MAD may have its
				designee complete an SOE for final review by MAD; however, MAD is ultimately
				responsible for the submission of its SOE. An SOE is submitted by MAD to the
				ALJ and claimant or the claimant's authorized representative within specified
				timeframes.
(2) A claimant or the
				claimant's authorized representative may submit an SOE to provide the ALJ with
				information to refute MAD's SOE. A claimant or the claimant's authorized
				representative is not required to provide a SOE, as the burden of proof falls
				on MAD.
(3) The MAD SOE shall, at a
				minimum, contain:
(a) the claimant's name,
				and as applicable, his or her authorized representative's or legal counsel's
				telephone number and address, and the status of any previous or concurrent
				appeal through his or her MCO or MAD UR contractor;
(b) the adverse action against the
				claimant;
(c) the documentation
				supporting MAD, its UR contractor, or the MCO basis for the intended or taken
				adverse action; and
(d) any
				applicable federal or state statutes, regulations, rules or any combination of
				these; however, that a failure by MAD, the UR contractor or a MCO to submit an
				applicable statute, regulation or rule shall not constitute per se grounds for
				the ALJ to find that MAD, the UR contractor or the MCO failed to meet its
				burden of proof.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 352 - ADMINISTRATIVE HEARINGS › Part 2 - CLAIMANT HEARINGS › Section 8.352.2.15 - ADMINISTRATIVE HEARING STANDARDS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Administrative law judge.
(1) A
				HSD administrative hearing is conducted by an impartial official who:
(a) does not have any personal stake or
				involvement in the case; and
(b)
				was not involved in the determination or the action which is being contested;
				if the ALJ had any involvement with the action in question, including giving
				advice or consultation on the points at issue, or is personally related in any
				relevant degree to the parties, the ALJ must disqualify his or herself as the
				assigned ALJ for that case.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 352 - ADMINISTRATIVE HEARINGS › Part 2 - CLAIMANT HEARINGS › Section 8.352.2.17 - HSD ADMINISTRATIVE HEARING FINAL DECISION

Current through Register Vol. 35, No. 13, July 16, 2024
The final decision concerning the HSD administrative hearing
				  is made by the MAD director or designee after the review of the HSD
				  administrative hearing record and the ALJ's recommendation. If the ALJ had
				  rendered a decision to dismiss a HSD administrative hearing request, that
				  decision becomes the HSD administrative hearing final decision and the
				  following process detailed in this section of the rule does not apply.
A.
Decision based on the record:
The ALJ's HSD administrative hearing recommendation must be based solely on the
				record of the HSD administrative hearing.
B.
ALJ recommendation:
The ALJ
				shall review the record of the HSD administrative hearing and submit a complete
				copy of the record to the MAD director.
(1)
				Content of the ALJ recommendation: the ALJ shall specify the reasons for his or
				her conclusions, identifies the supporting evidence, references the pertinent
				federal and state statutes, regulations, and NMAC rules, and responds to the
				arguments of the parties within his or her written report.
(2) The ALJ recommends:
(a) in favor of the claimant if MAD, its UR
				contractor or the MCO's intended or taken adverse action is not supported by a
				preponderance of the evidence submitted during the HSD administrative hearing.
				The ALJ will provide specific recommendations to each appealed adverse
				action;
(b) in favor of MAD, if the
				preponderance of evidence submitted during the HSD administrative hearing
				supports the intended or taken of adverse action or actions; or
(c) any other result supported by the record
				of the HSD administrative hearing which may be a combination of recommendations
				for and against the claimant or MAD. If the HSD administrative hearing covered
				a number of services or components of a service, the ALJ will provide specific
				recommendations to each intended or taken adverse action.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 352 - ADMINISTRATIVE HEARINGS › Part 2 - CLAIMANT HEARINGS › Section 8.352.2.18 - CONTINUATION OF BENEFITS PURSUANT TO A TIMELY APPEAL AND A HSD ADMINISTRATIVE HEARING PROCEEDING

Current through Register Vol. 35, No. 13, July 16, 2024
A continuation of an existing benefit is provided to a
				  claimant who is not a member of a MCO when the claimant requests a continuation
				  of the benefit through MAD or its UR contractor as directed on the claimant's
				  notice of action within 10 calendar days of the mailing of the MAD or its UR
				  contractor's notice of action. A continuation of the benefit is provided to a
				  member who requests a continuation of the benefit through his or her MCO within
				  10 calendar days of the mailing of the MCO's notice of action. The MAD, its UR
				  contractor or the MCO's notice of action will include information on the rights
				  to the continued benefit and on the claimant or member's responsibility for
				  repayment if the MCO final appeal decision and, as applicable, the HSD
				  administrative hearing decision is not in his or her favor. The continuation of
				  a benefit is only available to a member or claimant that is currently receiving
				  the appealed benefit. The continuation of the benefit will be the same as the
				  member or claimant's current allocation, budget or LOC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 352 - ADMINISTRATIVE HEARINGS › Part 2 - CLAIMANT HEARINGS › Section 8.352.2.19 - IMPLEMENTATION OF THE HSD ADMINISTRATIVE FINAL DECISION

Current through Register Vol. 35, No. 13, July 16, 2024
The HSD administrative hearing final decision is binding on
				  all issues that have been the subject of the HSD administrative hearing as to
				  the claimant unless stayed by either a court order or by the MAD director or
				  designee. MAD is responsible for ensuring that the HSD administrative hearing
				  final decision is fulfilled.
A. If the
				claimant is a member and he or she received a benefit under his or her approved
				continuation of the benefit and the decision is favorable to the MCO, the
				claimant's MCO will take action to file a repayment claim to the claimant or
				the claimant's authorized representative for the services received during the
				MCO appeal and the HSD administrative hearing process up to the date of the HSD
				administrative hearing final decision. The claimant is responsible for
				repayment to his or her MCO the amount of paid claims for the continuation of
				the benefit beginning on the first date of service of the claimant's approved
				continuation of the benefit up to and including the date of the HSD
				administrative hearing final decision. The claimant's MCO is charged with the
				collection of this amount. The repayment amount must be used by the claimant's
				MCO to benefit its members.
B. If
				the claimant is not enrolled in a MCO and the HSD administrative hearing final
				decision is favorable to MAD or its UR contractor, MAD will take action to file
				a repayment claim to the claimant or the claimant's authorized representative
				for the services received during the HSD administrative hearing process up to
				the date of the HSD administrative hearing final decision.
C. When the HSD administrative hearing final
				decision is favorable to the claimant, MAD, its UR contractor or MCO will
				authorize the benefit and coverage set forth in the HSD administrative hearing
				final decision.
D. A request for a
				HSD administrative hearing concerning the MAD or MCO repayment claim is limited
				to alleging errors in how the repayment amount was determined. The HSD final
				administrative hearing decision serves as the claimant's notice of action from
				either the MCO or MAD to start collection proceedings.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 352 - ADMINISTRATIVE HEARINGS › Part 2 - CLAIMANT HEARINGS › Section 8.352.2.20 - JUDICIAL APPEAL

Current through Register Vol. 35, No. 13, July 16, 2024
If the HSD administrative hearing final decision upholds MAD,
				  its UR contractor or the MCO's intended or taken adverse action, the claimant
				  or the claimant's authorized representative has the right to pursue judicial
				  review of the HSD administrative hearing final decision and is notified of that
				  right in the HSD administrative final decision letter. Judicial appeals for the
				  HSD administrative hearing final decision are governed by New Mexico statutes
				  and court rules. While the following subsections highlight applicable
				  procedures, they should not be considered a substitute for examining the
				  statutes and rules themselves.
A.
Jurisdiction:
Administrative appeals for a claimant are governed
				by the Section
				39-3-1.1
				NMSA 1978 and by Rule 1-074, Rules of Civil Procedures for the District
				Courts.
B.
Timeliness:
Unless otherwise provided by law, a claimant or the claimant's authorized
				representative must appeal the HSD administrative hearing final decision within
				30 calendar days of the date of the HSD administrative hearing final decision
				by filing a notice of appeal with the clerk of the appropriate New Mexico
				district court.
C.
Jurisdiction and standard of review:
All judicial appeals are
				based on the record made at the HSD administrative hearing, and in accordance
				with state statute and court rules. HSD files a copy of the HSD administrative
				hearing record with the court clerk and furnishes one copy to the claimant or
				the claimant's authorized representative and if applicable, his or her legal
				counsel within 30 calendar days after receipt of the notice of appeal. The
				court may set aside the HSD administrative hearing final decision if it finds
				the decision is:
(1) arbitrary, capricious,
				or an abuse of discretion;
(2) is
				not supported by substantial evidence in the record as a whole; or
(3) is otherwise not in accordance with the
				applicable law, statutes or rules.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 352 - ADMINISTRATIVE HEARINGS › Part 3 - PROVIDER HEARINGS › Section 8.352.3.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program and other health care
				  programs are administered pursuant to regulations promulgated by the federal
				  department of health and human services under Title XIX of the Social Security
				  Act as amended or by state statute. See NMSA 1978, Section 27-2-12 et seq.
				  Section 9-8-1 et seq. NMSA 1978 establishes the health care authority (HCA) as
				  a single, unified department to administer laws and exercise functions relating
				  to health care facility licensure and health care purchasing and
				  regulation.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 352 - ADMINISTRATIVE HEARINGS › Part 3 - PROVIDER HEARINGS › Section 8.352.3.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of this rule is to provide instruction for the
				  service portion of the New Mexico medical assistance programs
				  (MAP).
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 352 - ADMINISTRATIVE HEARINGS › Part 3 - PROVIDER HEARINGS › Section 8.352.3.8 - MISSION STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
To reduce the impact of poverty on people living in New
				  Mexico by providing support services that help families break the cycle of
				  dependency on public assistance.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 352 - ADMINISTRATIVE HEARINGS › Part 3 - PROVIDER HEARINGS › Section 8.352.3.9 - PROVIDER ADMINISTRATIVE HEARINGS

Current through Register Vol. 35, No. 13, July 16, 2024
With the exception of referrals for credible allegations of
				  fraud, HSD has established a hearing process for MAD fee-for-service (FFS)
				  providers who disagree with its decision concerning his or her participation as
				  a MAD provider, recoupment of overpayments due to a provider billing error, and
				  the imposition of MAD sanctions. For the provider administrative hearing
				  process concerning decisions on noncompliance with nursing facility (NF) or
				  intermediate care facility for individuals with intellectual disabilities
				  (ICF-IID) provider certification requirements also see hearing regulations
				  promulgated by the department of health (DOH) and specific MAD New Mexico
				  administrative code (NMAC) rules applicable to the provider. See 8.311.3 NMAC,
				  8.312.2 NMAC, and 8.313.3 NMAC for a detailed description of the appeals
				  process for audit settlements. See 8.308.14 NMAC for a detailed description of
				  the grievance and appeal process for resolving provider disputes between a HSD
				  contracted managed care organization (MCO) and its contractor or subcontractor.
				  For applicable rules for services and items provided through a MAD coordinated
				  service contractor, see 8.349.2 NMAC.
A.
Provider administrative hearing
				rights:
The right to a provider administrative hearing includes the
				right to:
(1) be advised of the nature and
				availability of a provider administrative hearing;
(2) be represented by his or her authorized
				representative or legal counsel;
(3) have a provider administrative hearing
				which safeguards the provider's opportunity to present a case;
(4) have prompt notice and implementation of
				the final provider administrative hearing decision; and
(5) be advised that judicial review may be
				invoked to the extent such review is available under state law.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 352 - ADMINISTRATIVE HEARINGS › Part 3 - PROVIDER HEARINGS › Section 8.352.3.10 - INITIATION OF FFS PROVIDER ADMINISTRATIVE HEARING PROCESS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Notice:
When applicable, the
				provider administrative hearing process is initiated by a provider's request
				for hearing made in response to a MAD action notice. See Section 8.351.2 NMAC
				for a detailed description of notice requirements when the action is a MAD
				sanction.
B.
Time
				limits:
A MAD FFS provider has 30 calendar days from the date of the MAD
				action notice to request a provider administrative hearing. To be considered
				timely, the request must be received by the HSD fair hearings bureau (FHB) no
				later than the close of business of the 30th day. Provider administrative
				hearings are conducted and a written decision is issued by the MAD director or
				designee to the provider within 120 calendar days from the date the FHB
				receives the provider administrative hearing request, unless the parties
				otherwise agree to an extension. See 8.351.2 NMAC for information concerning
				time limits when the action is a MAD sanction. The right to request a stay is
				cited in 8.351.2.15 NMAC.
C.
Scope and limits on provider administrative hearings:
(1) A provider administrative hearing is
				available to all MAD FFS providers, including providers applying for electronic
				health record incentive payments, who submit a request in accordance with all
				sections of this rule. A provider can request a hearing if:
(a) his or her PPA or renewal of his or her
				PPA is denied;
(b) the provider's
				MAD participation is suspended or terminated;
(c) the provider disagrees with a decision of
				MAD or its designee with respect to recovery of overpayments due to provider
				billing error including incorrect billing, or lack of documentation to support
				the medical necessity of a service, or that the service was provided, or
				imposition of a sanction or other remedy, with the exception of a temporary
				payment suspension for credible allegations of fraud; or
(d) the provider believes the requirements
				for timely filing of a claim as stated in 8.302.2 NMAC were met but a decision
				by MAD has been made that the timely filing requirements were not
				met.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 352 - ADMINISTRATIVE HEARINGS › Part 3 - PROVIDER HEARINGS › Section 8.353.3.12 - HEARING STANDARDS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Rights at hearing:
The parties are given an opportunity to:
(1) present their case or have it presented
				by his or her authorized representative or legal counsel;
(2) bring witnesses to present information
				relevant to the case;
(3) submit
				evidence to establish all pertinent facts and circumstances in the
				case;
(4) advance arguments without
				undue interference; and
(5)
				question or contradict any testimony or evidence, including an opportunity to
				confront and cross-examine opposing witnesses.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 352 - ADMINISTRATIVE HEARINGS › Part 3 - PROVIDER HEARINGS › Section 8.352.3.13 - CONDUCTING THE HEARING

Current through Register Vol. 35, No. 13, July 16, 2024
A provider administrative hearing is conducted in an orderly
				  manner and in an informal atmosphere. The provider administrative hearing is
				  conducted in person or telephonically and is not open to the public. The ALJ
				  has the authority to limit the number of persons in attendance if space or
				  other considerations dictate.
A.
Opening the provider administrative hearing:
The hearing is opened
				by the ALJ. Individuals present must identify themselves for the record. The
				ALJ explains his or her role in the proceedings, and that the final decision on
				the appeal will be made by the MAD director after review of the proceedings and
				the ALJ's recommendation. The order of testimony is described, and the oath is
				administered to all who will testify at the hearing.
B.
Order of testimony:
The order
				of testimony at the provider administrative hearing is as follows:
(1) opening statements of parties or their
				representatives;
(2) presentation
				of MAD's case; if witnesses are called, the order of examination of each
				witness is:
(a) examination by the MAD
				representative;
(b) cross
				examination by the provider, his or her authorized representative or legal
				counsel; and
(c) opportunity to
				redirect the witness;
(3) presentation of the provider's case; if
				witnesses are called, the order of examination of each witness is:
(a) examination by provider, his or her
				authorized representative or legal counsel;
(b) cross examination by MAD or its selected
				claims and provider enrollment processing contractor; and
(c) opportunity to redirect the
				witness;
(4)
				presentation of rebuttal evidence by MAD and provider, respectively;
(5) the ALJ may direct further questions to
				the MAD representative, the provider, or any witnesses to clarify
				inconsistencies or obtain an adequate evidentiary record; and
(6) the ALJ may ask parties to summarize and
				present closing arguments.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 352 - ADMINISTRATIVE HEARINGS › Part 3 - PROVIDER HEARINGS › Section 8.352.3.14 - HEARING DECISION

Current through Register Vol. 35, No. 13, July 16, 2024
The final HSD provider administrative hearing decision
				  concerning the hearing is made by the MAD director or designee after review of
				  the record and the ALJ's report and recommendation.
A.
Decision based on the record:
The ALJ's recommendation may be adopted or rejected in a final written decision
				by the MAD director or designee on issues that were the subject of the hearing.
				The MAD director or designee specifies the reasons for the decision and
				identifies the regulatory authority and the evidence supporting the decision,
				including the record created by the provider administrative hearing, applicable
				federal and state law, regulations and NMAC rules, policies and instructions or
				any combination of these. No person who participated in the original action
				under appeal or in the provider administrative hearing may participate in
				arriving at a final decision.
B.
ALJ recommendation:
The ALJ reviews the record of the provider
				administrative hearing and all applicable federal and state law, regulations
				and NMAC rules, policy and instructions or any combination of these, and
				evaluates the evidence submitted. The ALJ submits the complete record of the
				hearing, along with his or her written recommendation to the MAD director.
(1) Content of recommendation. The ALJ
				specifies the reasons for his or her conclusions, identifies the supporting
				evidence, references the applicable federal and state law, regulations and NMAC
				rules, policies and instructions or any combination of these, and responds to
				the arguments of the parties in a written report and recommendation.
(2) The ALJ recommends:
(a) in favor of the provider if MAD's action
				or proposed action is not supported by a preponderance of the evidence
				available as a result of the provider administrative hearing;
(b) in favor of MAD, if the preponderance of
				the evidence available supports the action or proposed action; or
(c) any other result supported by the
				record.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 352 - ADMINISTRATIVE HEARINGS › Part 3 - PROVIDER HEARINGS › Section 8.352.3.15 - IMPLEMENTATION OF DECISION

Current through Register Vol. 35, No. 13, July 16, 2024
The final HSD provider administrative hearing decision is
				  binding on all issues that were the subject of a hearing, as to the provider,
				  unless stayed by court order pending appeal. The decision is implemented within
				  the time frames specified below.
A.
Decision favorable to HSD:
Decisions favorable to MAD are
				implemented immediately, unless stayed by court order.
B.
Decision favorable to
				provider:
If the decision is in favor of the provider, MAD must
				immediately lift any sanctions in place and remit to the provider any funds
				being held pending the decision.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 352 - ADMINISTRATIVE HEARINGS › Part 3 - PROVIDER HEARINGS › Section 8.352.3.16 - JUDICIAL REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Right
				of appeal:
If the final HSD provider administrative hearing decision
				upholds MAD's original action or proposed action, the provider has the right to
				pursue judicial review of the decision and is so notified of that right in the
				decision.
B.
Timeliness:
The provider has 30 calendar days from the date of the
				provider administrative hearing decision to appeal that decision by filing an
				appropriate action for judicial review with the clerk of the first judicial
				district court and sending a copy of the notice of action to HSD and the
				ALJ.
C.
Jurisdiction and
				standard:
All appeals to the district court are based on a review of the
				record made at the hearing. The HSD office of general counsel files one copy of
				the hearing record with the clerk of the first judicial district court and
				furnishes one copy to the provider and his or her counsel within 20 calendar
				days after receipt of the notice of appeal.
D.
Stay pending appeal:
The
				district court decides, upon motion duly filed, whether the filing of the
				appeal will operate as a stay of the HSD final provider administrative hearing
				decision. If a stay is granted, the office of general counsel notifies
				appropriate staff concerning any necessary action.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 354 - PREADMISSION SCREENING AND ANNUAL RESIDENT REVIEW (PASRR) AND PATIENT STATUS POLICIES › Part 2 - PASRR AND PATIENT STATUS HEARINGS › Section 8.354.2.1 - ISSUING AGENCY

Current through Register Vol. 35, No. 13, July 16, 2024
New Mexico Health Care Authority.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 354 - PREADMISSION SCREENING AND ANNUAL RESIDENT REVIEW (PASRR) AND PATIENT STATUS POLICIES › Part 2 - PASRR AND PATIENT STATUS HEARINGS › Section 8.354.2.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
The rule applies to the general public.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 354 - PREADMISSION SCREENING AND ANNUAL RESIDENT REVIEW (PASRR) AND PATIENT STATUS POLICIES › Part 2 - PASRR AND PATIENT STATUS HEARINGS › Section 8.354.2.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program and other health care
				  programs are administered pursuant to regulations promulgated by the federal
				  department of health and human services under Title XIX of the Social Security
				  Act as amended or by state statute. See Section 27-1-12 et seq. NMSA 1978.
				  Section 9-8-1 et seq. NMSA 1978 establishes the health care authority (HCA) as
				  a single, unified department to administer laws and exercise functions relating
				  to health care facility licensure and health care purchasing and
				  regulation.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 354 - PREADMISSION SCREENING AND ANNUAL RESIDENT REVIEW (PASRR) AND PATIENT STATUS POLICIES › Part 2 - PASRR AND PATIENT STATUS HEARINGS › Section 8.354.2.4 - DURATION

Current through Register Vol. 35, No. 13, July 16, 2024
Permanent.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 354 - PREADMISSION SCREENING AND ANNUAL RESIDENT REVIEW (PASRR) AND PATIENT STATUS POLICIES › Part 2 - PASRR AND PATIENT STATUS HEARINGS › Section 8.354.2.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
August 1, 2014, unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 354 - PREADMISSION SCREENING AND ANNUAL RESIDENT REVIEW (PASRR) AND PATIENT STATUS POLICIES › Part 2 - PASRR AND PATIENT STATUS HEARINGS › Section 8.354.2.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program and other health care
				  programs are administered pursuant to regulations promulgated by the federal
				  department of health and human services under Title XIX of the Social Security
				  Act as amended or by state statute. See Section
				  27-1-12
				  et seq. NMSA 1978.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 354 - PREADMISSION SCREENING AND ANNUAL RESIDENT REVIEW (PASRR) AND PATIENT STATUS POLICIES › Part 2 - PASRR AND PATIENT STATUS HEARINGS › Section 8.354.2.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				"
Administrative law judge (ALJ)
" means the HSD fair hearings
				bureau's (FHB) appointed judge to oversee the claimant's administrative hearing
				process and render a recommendation to the medical assistance division (MAD)
				director.
B. "
Adverse
				action
"
:
means:
(1) the
				belief of a claimant or his or her authorized representative that his or her
				preadmission or annual resident review (PASRR) determination is erroneous;
				or
(2) the belief of a claimant or
				his or her authorized representative that the claimant's NF determination to
				transfer or discharge him or her is erroneous.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 354 - PREADMISSION SCREENING AND ANNUAL RESIDENT REVIEW (PASRR) AND PATIENT STATUS POLICIES › Part 2 - PASRR AND PATIENT STATUS HEARINGS › Section 8.354.2.8 - MISSION STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of this rule is to provide instruction for the
				  service portion of the New Mexico medical assistance
				  programs.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 354 - PREADMISSION SCREENING AND ANNUAL RESIDENT REVIEW (PASRR) AND PATIENT STATUS POLICIES › Part 2 - PASRR AND PATIENT STATUS HEARINGS › Section 8.354.2.9 - CLAIMANT OR THE CLAIMANT'S AUTHORIZED REPRESENTATIVE AND HSD ADMINISTRATIVE HEARING PROCESS

Current through Register Vol. 35, No. 13, July 16, 2024
HSD has established a hearing process for a MAP eligible
				  recipient or a MCO member who is adversely affected by the preadmission
				  screening and annual resident review (PASRR) or the transfer or discharge from
				  a NF as required by Section 1919(e)(7) of the Social Security Act.
A. Claimant:
(1) When an adverse action (see Subsection B
				of 8.354.2.7 NMAC) is intended or taken against a MAP eligible recipient by
				MAD, its UR contractor or their designee, the MAP eligible recipient may file
				as a claimant to request a HSD administrative hearing.
(2) When an adverse action (see Subsection B
				of 8.354.2.7 NMAC) is intended or taken against a member by his or her MCO or
				its designee, the member may file as a claimant to request a HSD administrative
				hearing. A member is not required to first exhaust his or her MCO appeal
				process prior to filing for a HSD administrative hearing when affected by an
				adverse action listed in 8.354.2.7 NMAC. Upon requesting a HSD administrative
				hearing, the member is referred to as the claimant and is governed by the
				remaining sections of this rule.
(3) A claimant must request a HSD
				administrative hearing within 90 calendar days of the mailing of either the
				notice of action or the denial for new service.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 354 - PREADMISSION SCREENING AND ANNUAL RESIDENT REVIEW (PASRR) AND PATIENT STATUS POLICIES › Part 2 - PASRR AND PATIENT STATUS HEARINGS › Section 8.354.2.10 - RIGHT TO A PASRR AND NURSING FACILITY TRANSFER OR DISCHARGE HSD ADMINISTRATIVE HEARING

Current through Register Vol. 35, No. 13, July 16, 2024
This specific type of a HSD administrative hearing is 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,
				  against an individual by MAD, it UR contractor, the MCO and their designees.
				  MAD or the MCO must grant an individual or the individual's authorized
				  representative the opportunity for a HSD administrative hearing under specific
				  circumstances pursuant to
				  42 CFR Section
				  431.220(a) and 27 - 3 - 3
				  NMSA 1978. A HSD administrative hearing occurs telephonically between the
				  parties to the HSD administrative hearing and the assigned FHB ALJ.
A. An individual or the individual's
				authorized representative may request a HSD administrative hearing based on his
				or her belief that MAD, its UR contractor, the MCO or their designees intends
				to take, or has taken, an adverse action.
B. MAD, its UR contractor, the MCO or their
				designees will not be responsible for any fees or costs, incurred by the
				individual or his or her authorized representative as a result of a HSD
				administrative hearing, or if he or she files an appeal of the HSD
				administrative hearing final decision to a New Mexico district court.