New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 15 - GRIEVANCES AND APPEALS › Section 8.308.15.13 - MCO EXPEDITED MEMBER APPEAL PROCESS

Current through Register Vol. 35, No. 13, July 16, 2024
The MCO shall establish and maintain an expedited review
				  process for a MCO expedited member appeal when the MCO, the member or his or
				  her authorized representative or authorized provider believes that allowing the
				  time for a standard member appeal resolution could seriously jeopardize the
				  member's life, health, or his or her ability to attain, maintain, or regain
				  maximum function. Once a member or his or her authorized representative or
				  authorized provider requests a MCO expedited member appeal and the member or
				  his or her authorized representative or authorized provider requests a
				  continuation of the member's disputed current benefit, the MCO will grant a
				  continuation of the disputed current benefit until the MCO expedited member
				  appeal final decision is rendered by the MCO. However, if the date of the MCO
				  expedited member appeal final decision letter is prior to the notice of
				  action's adverse action effective date, the MCO must continue the disputed
				  current benefit up to the adverse action's effective date. The MCO shall ensure
				  that health care professionals with appropriate clinical expertise in
				  addressing the physical health, behavioral health, or long-term services and
				  supports needs of the member are utilized during the MCO expedited member
				  appeal process when the MCO notice of action for the disputed benefit is based
				  on a lack of medical necessity.
A. A
				member or his or her authorized representative or authorized provider in
				accordance with the member's MCO procedures has the right to request within 60
				calendar days after the mailing of the MCO's notice of action a MCO expedited
				member appeal orally or in writing. When the mailing date of the notice of
				action is disputed or there is a discrepancy between the mailing date and the
				postmarked date, the postmarked date will prevail.
(1) If a member, his or her authorized
				representative or authorized provider elects to request a continuation of the
				member's disputed current benefit, the member or his or her authorized
				representative or authorized provider must request a MCO expedited member
				appeal and request a continuation of the member's disputed current benefit
				within 10 calendar days of the mailing of the MCO's notice of action. When the
				mailing date of the notice of action is disputed or there is a discrepancy
				between the mailing date and the postmarked date, the postmarked date will
				prevail. The continuation of the disputed current benefits is not dependent on
				the approval to proceed to the MCO expedited appeal process. See
				8.308.15.15
				NMAC for a detailed description of the continuation of the disputed benefit
				process.
(2) If the member or
				authorized representative or authorized provider requests a MCO expedited
				member appeal, the following applies.
(a) If
				the member or his or her authorized representative designate in writing the
				member's provider to act as the member's authorized provider, the authorized
				provider may request a MCO expedited member appeal when the authorized provider
				believes that the MCO has made an incorrect decision concerning the member's
				disputed benefit.
(b) If the MCO
				upholds its adverse action, regardless of who requested the MCO expedited
				member appeal process, the MCO expedited member appeal process is considered
				exhausted and the member or his or her authorized representative may request a
				HSD expedited or standard administrative hearing concerning the member's
				disputed benefit.
(c) Once the
				member or his or her authorized representative request a HSD expedited or
				standard administrative hearing, he or she is referred to as the
				claimant.
(4) The member
				or his or her authorized representative or the authorized provider may have
				legal counsel or a spokesperson assist him or her during the MCO expedited
				member appeal process.
(5) The
				member or his or her authorized representative or the authorized provider does
				not have the right to request a MCO expedited or standard member appeal or a
				HSD expedited or standard administrative hearing related to a value-added
				service offered by the MCO.
(6) The
				authorized provider is not eligible to request a HSD expedited or standard
				administrative hearing on the disputed benefit, unless the provider has been
				designated as the member's authorized representative. See 8.352.2 NMAC for a
				detailed description of the HSD expedited and standard administrative hearing
				processes.