reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 3 - PAYMENT OF CLAIMS, POST-ACCIDENT DRUG AND ALCOHOL TESTING, AND CONDUCT OF PARTIES › Section 11.4.3.14 - CONDUCT OF ATTORNEYS AND REPRESENTATIVES APPEARING BEFORE THE WCA

Current through Register Vol. 35, No. 13, July 16, 2024
A. An attorney or
				other representative of a party may not engage in or advocate meritless claims
				or defenses when appearing before the WCA.
B. An attorney or other representative of a
				party shall be courteous and professional and shall be punctual for mediations
				and hearings.
C. Attorneys and
				other representatives of a party shall be attired in an appropriate manner,
				suitable to a court proceeding.
D.
				The director may sanction any attorney or representative who engages in the
				conduct proscribed by Subsections A, B and C of this Section or who violates
				any provision of the Act or these rules. In cases of repeated violations, or a
				single act of an egregious nature, and upon a written finding that the attorney
				or representative's behavior is not likely to be controlled by imposition of a
				fine, the director's sanctions may include suspension, termination or
				limitation of the right to practice before the WCA.
E. The director's imposition of a sanction
				against an attorney or representative shall be governed by the procedures in
				11.4.5 NMAC.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 3 - PAYMENT OF CLAIMS, POST-ACCIDENT DRUG AND ALCOHOL TESTING, AND CONDUCT OF PARTIES › Section 11.4.3.15 - ENFORCEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
Any violation of these rules may be investigated and
				  penalized pursuant to the procedures in 11.4.5 NMAC.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 4 - CLAIMS RESOLUTION › Section 11.4.4.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
These rules apply to parties involved in claims arising under
				  the Workers' Compensation Administration Act and Occupational Disease and
				  Disablement Law (collectively "the act").
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 4 - CLAIMS RESOLUTION › Section 11.4.4.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Section
				  52-5-4 NMSA 1978 authorizes the
				  director to adopt reasonable rules and regulations for effecting the purposes
				  of the act.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 4 - CLAIMS RESOLUTION › Section 11.4.4.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of 11.4.4 NMAC is to establish rules governing
				  the resolution of claim disputes under the act, including but not limited to
				  the process for filing and service of pleadings and the conduct of mediation
				  conferences, discovery, and formal hearings.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 4 - CLAIMS RESOLUTION › Section 11.4.4.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
See
				  11.4.1.7 NMAC.
A.
"Initial pleading"
means a
				workers' compensation complaint, application to workers' compensation judge,
				application to director, petition for lump sum payment, or notice of change of
				HCP that opens or reopens an action or case before the WCA.
B.
"Insurer"
means any workers'
				compensation insurance carrier, a self-insured association or group, an
				individual self-insured employer, or a third-party claims administrator
				operating in the state of New Mexico.
C.
"Party representative"
means
				an individual or firm that enters an appearance before the WCA to represent or
				advocate on behalf of a named party. This may include attorneys licensed to
				practice law in the state of New Mexico, as well as claims administration or
				adjusting personnel.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 4 - CLAIMS RESOLUTION › Section 11.4.4.8 - OMBUDSMAN RULES

Current through Register Vol. 35, No. 13, July 16, 2024
A. An ombudsman
				shall provide information and facilitate communication regarding the act. An
				ombudsman is required to maintain a neutral position when providing information
				or facilitating communication. When responding to inquiries, an ombudsman
				shall:
(1) confer with workers, employers,
				insurers, HCPs or other interested persons;
(2) provide information or facilitate
				communication, when requested, about:
(a)
				individual rights and responsibilities established by the act;
(b) medical proof required to establish or
				deny the right to workers' compensation;
(c) HCP selection;
(d) mediation conferences, related forms, and
				other administrative practices and procedures;
(e) determination of disability;
(f) the right to representation by a lawyer
				or the right to proceed as a pro se party; and
(g) other disputes arising under the
				act;
(3) help workers,
				employers, insurers, HCPs or other interested parties complete administrative
				forms for submission to the administration;
(4) actively inquire into matters presented
				by workers, employers, insurers, HCPs or other interested persons. An ombudsman
				shall contact the parties involved and attempt to resolve the problem
				informally; and
(5) refer all
				inquiries concerning uninsured employers to the WCA employer compliance
				bureau.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 4 - CLAIMS RESOLUTION › Section 11.4.4.10 - MEDIATION RULES

Current through Register Vol. 35, No. 13, July 16, 2024
A. Mediation of
				complaints:
(1) The director's designee, a
				mediator, shall evaluate all initial complaints in new cases.
(2) The mediator shall evaluate and mediate
				the merits of the complaint for jurisdiction, proper parties, compensability,
				the nature and extent of any benefits due the worker, and the strength or
				availability of any defenses. A mediator may also evaluate the compliance of
				the parties with the mediation rules.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 4 - CLAIMS RESOLUTION › Section 11.4.4.11 - DIRECTOR'S MATTERS

Current through Register Vol. 35, No. 13, July 16, 2024
A. The
				following matters shall be pleaded on the mandatory application to director
				form:
(1) judge assignment
				disputes;
(2) request for relief
				from an untimely rejection of a recommended resolution;
(3) request to withdraw an acceptance of a
				recommended resolution;
(4)
				appointment of a recipient of benefits for a minor child or an incompetent
				worker;
(5) approval of an out of
				state health care provider, if necessary;
(6) attorney withdrawal when no judge is
				assigned;
(7) objection to case
				management or utilization review by the WCA; and
(8) any other matter within the director's
				jurisdiction.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 4 - CLAIMS RESOLUTION › Section 11.4.4.12 - HCP RULES

Current through Register Vol. 35, No. 13, July 16, 2024
A. HCP general
				provisions:
(1) These rules apply to claims
				governed by the 1990 amendments to the act.
(2) The assigned judge shall decide HCP
				choice disputes. If no judge has been assigned, a judge shall be appointed by
				the clerk solely to resolve the HCP dispute.
(3) The HCP judge appointed by the clerk is
				not assigned pursuant to Subsection C of Section
				52-5-5 NMSA 1978. The peremptory
				right to disqualify a judge allowed by Subsection D of Section
				52-5-5 NMSA 1978, does not apply
				to the appointment of the HCP judge.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 4 - CLAIMS RESOLUTION › Section 11.4.4.13 - ADJUDICATION PROCESS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Assignment
				of judge:
(1) Upon receipt of a timely
				rejection of a recommended resolution, an application to judge or petition for
				lump sum payment, the clerk shall assign a judge to the case and shall serve
				notice on all parties. Pro se parties shall be served by certified mail unless
				registered with the WCA electronic filing system. This notice shall be
				considered the initial notice of judge assignment.
(2) Each party shall have the right to
				disqualify a judge by filing a notice of disqualification of judge no later
				than 10 days from the date of filing of the notice of assignment of judge. The
				clerk shall assign a new judge to the case and notify all registered parties. A
				party who has not exercised the right of disqualification may do so no later
				than 10 days from the filing of the notice of reassignment of judge.
(3) No action may be taken by any judge on a
				case until the expiration of the time for all parties to exercise the
				peremptory right to disqualify a judge. To expedite the adjudication process,
				the parties may file a joint waiver of the right to disqualify a judge. Such
				waiver shall forever bar the parties' right to disqualify a judge in that
				case.
(4) Disputes related to the
				assignment, re-assignment, or disqualification of a judge shall be raised by
				written application to the director, which shall be filed with the
				clerk.
(5) The director may
				designate an on-call judge for the limited purpose of reviewing and approving
				lump sum payment petitions on a voluntary walk-in basis. The director shall
				provide notice to the public about the schedule for any on-call judge
				availability. Such designation shall not be considered a judge assignment or
				reassignment under this section if further adjudication action is
				needed.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 4 - CLAIMS RESOLUTION › Section 11.4.4.14 - WITHDRAWAL AND SUBSTITUTION OF COUNSEL

Current through Register Vol. 35, No. 13, July 16, 2024
A. The entry of appearance of an attorney or
				a firm for a party in a pending case shall not be withdrawn without permission
				of the judge or by the director if no judge has been assigned to the case. A
				motion to the judge or application to director requesting withdrawal shall be
				filed with the clerk and shall indicate whether the client concurs with the
				withdrawal.
B. A motion to the
				judge or application to director seeking withdrawal of counsel shall clearly
				state whether the withdrawing attorney is asserting a request for attorneys'
				fees for services rendered. If no statement is made, and if the motion or
				application to withdraw is granted, the withdrawing attorney is barred from
				thereafter seeking attorneys' fees for services rendered on the case. A
				statement asserting a request for attorneys' fees shall serve as notice to the
				parties and new legal counsel, if any.
C. When a new attorney assumes a case, a
				notice of substitution of counsel shall be filed and served on each party. The
				notice shall contain the new attorney's mailing address, phone number, and
				e-mail address.
D. The attorney of
				record shall be subject to notice of hearings or other proceedings until
				permitted to withdrawal from the case.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 4 - CLAIMS RESOLUTION › Section 11.4.4.15 - APPROVAL OF ATTORNEY FEES AND LIENS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Parties may request the award of attorney
				fees by application to a judge. The application must contain sufficient
				information to determine if the fee requested is appropriate. The contested
				application should indicate the date and terms of any offers of settlement
				made; the present value of the benefits awarded the worker, including, but not
				limited to medical expenses and past and future weekly benefits; the total
				number of hours reasonably expended by counsel to secure benefits for the
				worker; the hourly billing rate of counsel; and any other relevant information
				for the determination of fees.
B.
				No attorney fees shall be paid until the case has been settled or adjudged. For
				purposes of the act, settled or adjudged includes:
(1) the entry of a compensation order;
				or
(2) the acceptance by both
				parties of a recommended resolution; or
(3) an order granting or denying any petition
				or application when no other cases are pending before the administration;
				or
(4) the WCA has administratively
				closed the file; or
(5) when there
				is a good faith belief that all pending issues or questions have been resolved,
				whether or not the jurisdiction of the administration has been
				invoked.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 4 - CLAIMS RESOLUTION › Section 11.4.4.16 - SANCTIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A. The judge may
				sanction any party, attorney, or personal representative for conduct that
				interferes with the orderly administration of the court or a hearing,
				including, but not limited to:
(1) rejecting a
				recommended resolution without reasonable basis, or without reasonable
				expectation of doing better at formal hearing;
(2) failing to obey a lawful order of the
				court;
(3) failing to appear for a
				hearing or deposition; or
(4)
				advancing a meritless position in order to harass or vex the opposing
				party.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 4 - CLAIMS RESOLUTION › Section 11.4.4.17 - SEALING OF PUBLIC COURT RECORDS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				Public court records filed with the clerk of court or offered as evidence in an
				administrative or adjudicative hearing shall not be sealed based solely on the
				agreement or stipulation of the parties.
B. The party requesting to seal court records
				subject to public inspection shall establish the same requirements for sealing
				court records as set forth in the rules of civil procedure for the district
				courts of New Mexico.
C. The order
				sealing the court records may seal the records from public inspection but shall
				not prohibit WCA staff from accessing the court record as necessary to enforce
				the provisions of the act.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 5 - ENFORCEMENT AND ADMINISTRATIVE INVESTIGATIONS › Section 11.4.5.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
Rules apply to any party to a claim arising under the act and
				  any person receiving medical payments from an employer under the
				  act.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 5 - ENFORCEMENT AND ADMINISTRATIVE INVESTIGATIONS › Section 11.4.5.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Section
				  52-5-4
				  NMSA 1978 (Repl. Pamp. 1991), authorizes the WCA to adopt reasonable rules and
				  regulations for effecting the purposes of the act. Section
				  52-1-28.1
				  NMSA 1978 (Repl. Pamp. 1991), authorizes the director to promulgate rules and
				  regulations regarding the prohibition against bad faith and unfair claims
				  processing. Section
				  52-5-1.3 NMSA
				  1978 (Repl. Pamp. 1991), empowers the director to investigate, penalize or
				  refer allegations of fraud. Section
				  52-1-61 NMSA
				  1978 (Repl. Pamp. 1991), authorizes the director to penalize persons who
				  violate the provisions of the act.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 5 - ENFORCEMENT AND ADMINISTRATIVE INVESTIGATIONS › Section 11.4.5.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
October 1, 2014, unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 5 - ENFORCEMENT AND ADMINISTRATIVE INVESTIGATIONS › Section 11.4.5.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The purpose of this rule is to provide a method for
				  enforcement by the WCA of the prohibition against bad faith, unfair claims
				  processing, fraud, and of any other obligation of a party or agent of a party
				  under the act and the WCA rules and regulations.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 5 - ENFORCEMENT AND ADMINISTRATIVE INVESTIGATIONS › Section 11.4.5.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A. "Enforcement
				Bureau" means the division of the WCA charged with investigating and
				prosecuting violations of the act or WCA rules.
B. See also 11.4.1.7 NMAC.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 5 - ENFORCEMENT AND ADMINISTRATIVE INVESTIGATIONS › Section 11.4.5.8 - INITIATION OF INVESTIGATION

Current through Register Vol. 35, No. 13, July 16, 2024
A. Any
				person may bring an allegation of prohibited conduct under the act, including
				criminal fraud, bad faith, unfair claims processing, retaliation, or
				non-compliance with the requirements of the act, to the attention of the WCA's
				enforcement bureau.
B. Any party
				may initiate a charge of bad faith, unfair claims processing, or retaliation by
				the filing of a complaint or an application to a judge.
C. The director may initiate an investigation
				of any act or pattern of action with potential for adverse impact upon the
				workers' compensation system by referring the matter for investigation to the
				enforcement bureau.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 5 - ENFORCEMENT AND ADMINISTRATIVE INVESTIGATIONS › Section 11.4.5.9 - CONDUCT OF INVESTIGATIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A. The
				enforcement bureau may serve a notice of pending investigation to appropriate
				persons or entities by hand delivery or certified mail, domestic return receipt
				requested, or by electronic mail for those parties registered with the
				WCA.
B. The notice of pending
				investigation shall identify, with reasonable specificity, the persons or
				entities subject to the investigation, and shall describe the alleged
				prohibited conduct.
C. Upon receipt
				of the notice of pending investigation, complainants and subjects must
				cooperate in the investigation of the charge. Upon request of the WCA, a party
				shall produce documentary evidence or other information related to a charge
				within the party's possession or control.
D. Upon receipt of the notice of pending
				investigation, complainants and subjects must make available any supervisor or
				employee for the purpose of permitting WCA personnel to take a statement
				regarding the charge.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 5 - ENFORCEMENT AND ADMINISTRATIVE INVESTIGATIONS › Section 11.4.5.10 - ENFORCEMENT OF THE ACT BY THE DIRECTOR

Current through Register Vol. 35, No. 13, July 16, 2024
A. These rules establish a procedure for the
				administrative enforcement of the act by the director. These rules do not
				govern procedure for criminal prosecution by the WCA's enforcement
				bureau.
B. Administrative
				enforcement proceedings shall be presided over by the director or designee and
				shall be conducted with dignity, in a manner conducive to
				deliberation.
C. Administrative
				enforcement hearings shall be recorded by a certified court monitor in
				compliance with the rules governing the recording of judicial proceedings
				adopted by the New Mexico supreme court.
D. No right of peremptory disqualification:
				The peremptory right of disqualification does not apply to proceedings
				conducted under the provisions of this rule.
E. The rules of civil procedure shall apply
				where not inconsistent with the provisions of these rules. The rules of
				evidence shall not apply. The rules of privilege shall apply to the extent that
				they are required to be recognized in civil actions in the district courts of
				New Mexico.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 5 - ENFORCEMENT AND ADMINISTRATIVE INVESTIGATIONS › Section 11.4.5.11 - INITIATION OF ADMINISTRATIVE ENFORCEMENT PROCEEDINGS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Commencement of action:
(1) An action may be commenced by the
				issuance of a notice of administrative enforcement proceeding by the
				enforcement bureau chief. The notice shall be delivered immediately to the
				director.
(2) The notice of
				administrative enforcement proceeding shall be in the form of a signed
				statement containing the name, address and phone number of the violator, a
				statement of facts, the specific violation charged and the specific rule or
				statutory provision violated.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 5 - ENFORCEMENT AND ADMINISTRATIVE INVESTIGATIONS › Section 11.4.5.12 - ADMINISTRATIVE ENFORCEMENT PROCEEDINGS BEFORE THE DIRECTOR

Current through Register Vol. 35, No. 13, July 16, 2024
For every case not referred to a workers' compensation judge
				  and upon the filing of the notice of administrative enforcement proceedings and
				  finding of probable cause:
A.
Summons:
A summons shall be issued by the clerk, directed to the
				alleged violator and must contain:
(1) The
				name and street address of the WCA, the docket number of the case and the name
				of the person(s) or entity the summons is directed to;
(2) A direction that the alleged violator
				shall appear before the director or director's designee in the manner
				prescribed by the summons, to respond to the charges;
(3) the time and place of the hearing,
				including video conference and telephone information if appropriate;
(4) A notice that unless the alleged violator
				appears as directed, the maximum proposed penalty may be imposed; and
(5) The name, address, telephone number and
				e-mail address of the prosecuting attorney for the enforcement
				bureau.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 5 - ENFORCEMENT AND ADMINISTRATIVE INVESTIGATIONS › Section 11.4.5.13 - MOTIONS AND DISCOVERY

Current through Register Vol. 35, No. 13, July 16, 2024
A. Unless
				otherwise stated in Part 5 or approved by the director, motion practice shall
				not be allowed in administrative enforcement proceedings.
B. The use of discovery is discouraged.
				Discovery may be approved only by the director or the director's designee, in
				exceptional circumstances where justice demands.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 5 - ENFORCEMENT AND ADMINISTRATIVE INVESTIGATIONS › Section 11.4.5.14 - SUBPOENAS

Current through Register Vol. 35, No. 13, July 16, 2024
A. The issuance of
				subpoenas to compel attendance at the hearing shall be issued pursuant to the
				Supreme Court Rules Annotated 1986, 1-045. The clerk of the WCA may issue a
				subpoena, signed but otherwise in blank, to a party requesting it, who shall
				complete it before service. An attorney authorized to practice law in New
				Mexico and who represents a party before the WCA, as an officer of the court,
				may also issue and sign a subpoena on behalf of the WCA.
B. Any objections to a subpoena shall be
				raised within five (5) days of actual receipt by filing a motion to quash with
				the WCA.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 5 - ENFORCEMENT AND ADMINISTRATIVE INVESTIGATIONS › Section 11.4.5.15 - HEARING

Current through Register Vol. 35, No. 13, July 16, 2024
A. The hearing
				shall be conducted expeditiously, but each party shall be permitted to present
				their position amply and fairly. The director may admit any documentary
				evidence, including hearsay evidence, provided that the evidence is relevant,
				has sufficient indicia of reliability and authenticity, and will assist the
				director in determining a fact or issue in dispute.
B. The parties shall have the right to call
				and cross examine witnesses. Oath of witnesses shall be administered by the
				director.
C. Following the hearing,
				the director may orally announce the decision and enter the appropriate
				order.
D. The director may delay
				issuing the decision for a period not exceeding 60 days if findings of facts
				and conclusions of law or briefs are to be submitted.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 5 - ENFORCEMENT AND ADMINISTRATIVE INVESTIGATIONS › Section 11.4.5.16 - PENALTIES

Current through Register Vol. 35, No. 13, July 16, 2024
A. If the director
				finds a violation of the act or these rules, a notice of penalty shall be
				filed. A notice of penalty shall contain sufficient facts to support the
				penalty, and the dollar amount of the penalty.
B. A party may request reconsideration of a
				notice of penalty by filing a motion for reconsideration within fifteen (15)
				days of service of the notice of penalty.
C. The director may file an action for
				enforcement of any final penalty in the appropriate district court if payment
				is not made within thirty (30) days of entry of the notice of penalty or within
				fifteen (15) days of an order on a motion for reconsideration.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 6 - JUDICIAL SELECTION › Section 11.4.6.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Section
				  52-5-2
				  NMSA 1978 (Repl. Pamp. 1991).
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 6 - JUDICIAL SELECTION › Section 11.4.6.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The purpose of this rule is to provide a mechanism for
				  selection of Judges that allows for public notice of vacancies, public comment
				  on reappointment of judges and public inspection of judicial
				  applications.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 6 - JUDICIAL SELECTION › Section 11.4.6.8 - JUDICIAL SELECTION

Current through Register Vol. 35, No. 13, July 16, 2024
A. The
				director may review the performance of workers' compensation judges at least
				once each year in a manner determined by the director.
B. The director shall announce the expiration
				of the term of a current workers' compensation judge not later than 120 days
				prior to the expiration of that term. Any incumbent seeking reappointment must
				apply to the director by filing an application for reappointment not later than
				110 days prior to the expiration of the term to which the incumbent was
				appointed.
C. After the director
				receives the application from the incumbent, the workers' compensation
				administration shall issue a request for public comment regarding the incumbent
				on its website, and by email solicitation from the WCA public information
				officer the workers' compensation community. Public comment shall be directed
				to the WCA general counsel office. The public comment period shall be open for
				two weeks.
D. Information relating
				to the incumbent that is obtained pursuant to these rules shall not be a public
				record under the inspection of public records act.
E. After the public comment period has ended,
				the general counsel office shall compile the information gathered from the
				public and provide it to the director without identifying information regarding
				the person or entity that provided the comment. All public comments will not be
				provided to the candidate, or if they are shared, that any identifying
				information will be redacted to protect the identity of the
				commentator.
F. The director shall
				review the public comment and the performance of each current judge on the 90th
				day prior to the expiration of each judge's term, or the closest business day
				thereto. The director shall consider any relevant factor including, but not
				limited to the performance of an incumbent judge, public comment regarding the
				incumbent judge, the continuing and projected need for judicial staffing and
				any factor that may be considered by the New Mexico judicial nominations
				commission for the district court in making a decision regarding
				reappointment.
G. Upon announcement
				of a judicial vacancy by the director, any candidate seeking appointment to the
				vacancy shall submit an application to the director in a standard format
				prepared by the director.
(1) All such
				applications shall be considered public records, not a record of the WCA for
				the purposes of Section
				52-5-21 NMSA 1978
				(1991).
(2) The director shall
				consider any relevant factor including, but not limited to the performance of a
				judicial candidate before the WCA, the continuing and projected need for
				judicial staffing and any factor that may be considered by the New Mexico
				judicial nominations commission for the district court in making a decision
				concerning appointment.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 7 - PAYMENTS FOR HEALTH CARE SERVICES › Section 11.4.7.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
This rule applies to workers, employers, and insurers and to
				  all workers' compensation health care services providers, caregivers,
				  pharmacies, and suppliers and all payers for such services and
				  supplies.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 7 - PAYMENTS FOR HEALTH CARE SERVICES › Section 11.4.7.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Sections, 52-4-2, 52-4-3, 52-4-5, 52-5-4, and NMSA
				  1978.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 7 - PAYMENTS FOR HEALTH CARE SERVICES › Section 11.4.7.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
January 1, 2023, unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 7 - PAYMENTS FOR HEALTH CARE SERVICES › Section 11.4.7.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The purpose of these rules is to establish and enforce a
				  system of maximum allowable fees and reimbursements for health care services
				  and related non-clinical services provided by all practitioners, to establish
				  billing dispute procedures and to establish the procedures for cost
				  containment, including case management, utilization review and Return-to-work
				  (RTW) services.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 7 - PAYMENTS FOR HEALTH CARE SERVICES › Section 11.4.7.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
The definitions in
				  11.4.1.7 NMAC shall apply to this
				  rule. In addition, the following definitions apply to the provision of all
				  services.
A.
"Business
				day"
means any day on which the WCA is open for business.
B.
"By-Report (BR)"
means a
				maximum amount for a service has not been established in the HCP fee
				schedule.
C.
"Cannabis
				Program"
means the State of New Mexico Department of Health Medical
				Cannabis Program.
D.
"Caregiver"
means any provider of health care services not defined
				and specified in Section
				52-4-1 NMSA 1978.
E.
"Case management"
means the
				on-going coordination of health care services provided to an injured or
				disabled worker including, but not limited to:
(1) developing a treatment plan to provide
				appropriate health care service to an injured or disabled worker;
(2) systematically monitoring the treatment
				rendered and the medical progress of the injured or disabled worker;
(3) assessing whether alternate health care
				services are appropriate and delivered in a cost-effective manner based upon
				acceptable medical standards;
(4)
				ensuring that the injured or disabled worker is following the prescribed health
				care plan; and,
(5) formulating a
				plan for the return to work.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 7 - PAYMENTS FOR HEALTH CARE SERVICES › Section 11.4.7.8 - GROUND RULES FOR BILLING AND PAYMENT

Current through Register Vol. 35, No. 13, July 16, 2024
A. Basic ground rules.
(1) These rules apply to all charges and
				payments for medical, other health care treatment, and related non-clinical
				services covered by the New Mexico Workers' Compensation Act and the New Mexico
				Occupational Disease Disablement Law.
(2) These rules shall be interpreted to the
				greatest extent possible in a manner consistent with all other rules
				promulgated by the WCA. In the event of an irreconcilable conflict between
				these rules and any other rules, the more specific set of rules shall
				control.
(3) Nothing in these rules
				shall preclude the separate negotiation of fees between a provider and a payer
				within the HCP fee schedule for any health care service as set forth in these
				rules.
(4) These rules and the
				director's HCP fee schedule order adopting the HCP fee schedule utilize the
				edition of the current procedural terminology referenced in the director's HCP
				fee schedule order, issued pursuant to Subsection A of
				11.4.7.9 NMAC. All references to
				specific CPT code provisions, in these rules shall be modified to the extent
				required for consistency with the director's HCP fee schedule order.
(5) Employers are required to inform a worker
				of the identity and source of their coverage for the injury or
				disablement.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 7 - PAYMENTS FOR HEALTH CARE SERVICES › Section 11.4.7.9 - FEES FOR HEALTH CARE SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				HCP fee schedule.
(1) The director shall issue
				an order pursuant to Section
				52-4-5 NMSA 1978 not less than
				once per annum setting the HCP fee schedule which shall list the maximum amount
				of reimbursement for, or the method for determining the maximum amount of
				reimbursement for medical services, treatments, devices, apparatus, and
				medicine.
(2) In addition to the
				HCP fee schedule, the director's HCP fee schedule order shall contain a brief
				description of the technique used for derivation of the HCP fee schedule and a
				reasonable identification of the data upon which the HCP fee schedule was
				based.
(3) The HCP fee schedule is
				procedure-specific and provider-neutral. Any code listed in the edition of the
				current procedural terminology adopted in the director's HCP fee schedule order
				may be used to designate the services rendered by any qualified provider within
				the parameters set by that provider's licensing regulatory agencies combined
				with applicable state laws, rules, and regulations.
(4) The HCP fee schedule shall be released to
				the public not less than 30 days prior to the date upon which it is adopted and
				public comments will be accepted during the 30 days immediately following
				release.
(5) After consideration of
				the public comments the director shall issue a final director's HCP fee
				schedule order adopting a HCP fee schedule, which shall state the date upon
				which it is effective. The final director's HCP fee schedule order shall be
				available at the WCA clerk's office not less than 20 days prior to its
				effective date.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 7 - PAYMENTS FOR HEALTH CARE SERVICES › Section 11.4.7.10 - QUALIFICATION OF OUT OF STATE HEALTH CARE PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
A. An HCP that is not licensed in the state
				of New Mexico must be approved by the director to qualify as an HCP under the
				act.
B. No party shall have
				recourse to the billing and payment dispute resolution provisions of these
				rules with respect to the services of an HCP who is not licensed in New Mexico
				or approved by the director.
C. The
				director's approval may be obtained by submitting an application to the
				director and proposed order, supported by an original affidavit of the HCP
				seeking approval. Nothing in this rule shall prevent the director from entering
				into agreements with any party or HCP to provide for simplified and expeditious
				qualification of HCPs in individual cases, provided, however, that all such
				agreements shall be considered public records.
D. The director's approval of a health care
				provider in a particular case, pursuant to the provisions of Section
				52-4-1 NMSA 1978 will be deemed
				given when an out of state health care provider provides services to that
				injured worker and the employer/insurer pays for those services. Unless
				otherwise provided, the approval obtained by this method will not apply to the
				provision of health care by that provider to any other worker, except by
				obtaining separate approval as provided in these rules.
E. The out of state health care provider
				shall comply with the New Mexico HCP fee schedule, however, nothing in these
				rules shall preclude the separate negotiation of fees between an out of state
				provider and a payer within the HCP fee schedule for any health care service as
				set forth in these rules.
F. In
				lieu of a formal director's approval, the payer may accept an original Out of
				State Health Care Provider Affidavit, as provided on the WCA website, from an
				HCP who is licensed by their state and in good standing.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 7 - PAYMENTS FOR HEALTH CARE SERVICES › Section 11.4.7.11 - BILLING AND PAYMENT DISPUTE RESOLUTION

Current through Register Vol. 35, No. 13, July 16, 2024
A. In the event of a billing or payment
				dispute any party may submit to the medical cost containment bureau a request
				for director's determination on the approved form located on the WCA
				website.
B. The request shall be
				made in writing within 30 days of the documented receipt date of the payer's
				disposition, nonpayment of the bill, or denial of a request for
				reconsideration. A request for director's determination shall consist of a
				brief explanation of the disputed billing and payment issue(s) and shall be
				accompanied by a copy of the bill(s) in question, a copy of the payer's
				explanation, and all supporting documentation necessary to substantiate the
				performance of the service(s) and the accuracy of the associated
				charges.
C. Upon receipt of a
				request, the administration will initially attempt to resolve the dispute
				informally. If this is unsuccessful, a notice of receipt of request for
				director's determination shall be filed with WCA clerk of the court and issued
				to both parties.
D. Both parties
				shall have 15 days from the date of the notice of receipt of request for
				director's determination to present to the WCA clerk of the court and opposing
				party any pertinent responses or appropriately captioned exhibits.
E. Parties who present responses or exhibits
				shall be responsible for service of such documents to all parties of
				record.
F. The director in his
				discretion may conduct such hearings and receive such evidence as is necessary
				to make a determination concerning the reasonableness and necessity of the
				services provided. A final determination shall issue within 45 days of the
				issuance of the notice of receipt of request for director's determination or
				the close of the hearing, whichever is later.
G. The director's determination of the
				billing and payment dispute is final. Any further attempt, directly or
				indirectly, to charge any party for any disallowed services or to fail to pay
				within 30 days of documented receipt of the director's determination for such
				services as may have been found to be due and owing shall be considered a
				violation of this rule.
H. The
				director's determination shall not be considered with regard to the
				compensability of the claim and shall have no legal force or effect beyond the
				resolution of the billing and payment disputes.
I. Any time frame set forth in
				11.4.7.11 NMAC may be waived by
				the director, in writing, for good cause shown.
J. Nothing in this rule shall prohibit the
				parties from resolving their billing dispute prior to or following referral to
				the administration.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 7 - PAYMENTS FOR HEALTH CARE SERVICES › Section 11.4.7.12 - INPATIENT ADMISSIONS, CASE MANAGEMENT AND UTILIZATION REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
A. Basic
				provisions.
(1) All workers and their legal
				representatives are required to cooperate with the WCA or its contractor, if
				any, with respect to all reasonable requests for information necessary for any
				provision of service.
(2) For the
				purpose of facilitating the provision of services, all employers, insurers, and
				third party administrators are required to communicate, cooperate and provide
				information, without charge, to the WCA or its contractor, if any.
(3) The WCA or its contractor, if any, shall
				report any refusal to cooperate to the director. Failure to provide requested
				information shall be presumed to be a refusal to cooperate. Any dispute
				concerning the reasonableness of any request for information may be submitted,
				in writing, to the director. The determinations of the director concerning the
				reasonableness of such requests are final.
(4) In any hearing before the WCA, the
				worker's refusal to cooperate in any services may be considered by a workers'
				compensation judge on the issues of reasonableness and necessity of medical
				charges or reasonableness, necessity, or appropriateness of medical
				treatment.
(5) The contractor shall
				avoid conflicts of interest or the appearance of impropriety when performing
				case management services and utilization review.
(6) Nothing in these rules prohibits an
				employer from establishing their own system of case management or utilization
				review at the employer's expense as provided in Section
				52-4-3 NMSA
				1978.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 7 - PAYMENTS FOR HEALTH CARE SERVICES › Section 11.4.7.13 - NON-CLINICAL SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
A. For
				medical records and report copies requested for the purpose of investigating or
				administering a workers' compensation claim, a practitioner may charge for
				paper and electronic copies as set forth in the HCP fee schedule, except as
				provided in Paragraphs (12), (13), (14) and (15) of Subsection C of
				11.4.7.8 NMAC. This fee is
				inclusive of any and all fees, including, but not limited to, administrative,
				processing, and handling fee of any kind.
B. A practitioner may charge for the
				completion of the WCA Form Letter to Health Care Provider the amount set forth
				in the HCP fee schedule.
C. A
				practitioner may charge for the completion of the WCA Provider's Report of
				Physical Ability according to the criteria and amount set forth in the HCP fee
				schedule.
D. Depositions
(1) An HCP may not charge more than $400 for
				the first hour or any portion thereof; and not more than $360 per hour for the
				second and subsequent hours, prorated in five minute increments. An HCP may not
				charge more than $200 for the first hour of deposition preparation time
				actually spent, and not more than $120 per hour for the second or third hours,
				prorated in five minute increments, up to a maximum of three hours.
(2) No compensation shall be paid for travel
				time to or from the deposition, waiting time prior to the scheduled beginning
				of the deposition, or time spent reading or correcting depositions. For good
				cause shown, a judge may enter a written order providing recompense to an HCP
				for reading and correcting a deposition.
(3) An HCP may require that they be paid for
				the first hour of the deposition testimony either before or at the time of the
				deposition.
(4) A non-refundable
				fee of up to $400 may be charged by an HCP for deposition appointments at which
				the attorney making the appointment is a no-show or fails to cancel at least 48
				hours in advance.
(5) Any notice of
				deposition to a practitioner shall contain the following language: "The rules
				of the WCA provide a schedule of maximum permissible fees for deposition
				testimony. No more than $400 for the first hour and $360 for each subsequent
				hour is permitted. Fees for the second and subsequent hours shall be prorated
				in five minute increments. An HCP may not charge more than $200 for the first
				hour of deposition preparation time actually spent, and not more than $120 for
				the second or third hours, prorated in five minute increments, up to a maximum
				of three hours."
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 7 - PAYMENTS FOR HEALTH CARE SERVICES › Section 11.4.7.14 - ENFORCEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
Any complaint of a violation of these rules shall be made, in
				  writing, to the medical cost containment bureau, enforcement bureau, or
				  assigned workers' compensation judge, if any.
New Mexico Administrative Code › Title 11 - LABOR AND WORKERS' COMPENSATION › Chapter 4 - WORKERS' COMPENSATION › Part 7 - PAYMENTS FOR HEALTH CARE SERVICES › Section 11.4.7.15 - DATA ACQUISITION

Current through Register Vol. 35, No. 13, July 16, 2024
A. The
				insurer must report an inpatient hospital bill to the WCA within 10 to 90 days
				of payment of the bill. Reports may be submitted by mail, fax, or electronic
				media in batches daily, weekly, or monthly from the insurer or insurer's
				representative.
B. The paid
				inpatient services data shall be submitted in a format acceptable to the WCA.
				The economic research bureau shall distribute a specific set of instructions
				for the submission of required data.
If the required paid inpatient services data is not received
				  from payer as stated under Subsection A of this section, the economic research
				  bureau may petition for a hearing before the WCA director and seek penalties
				  pursuant to Section
				  52-1-61 NMSA
				  1978.