New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.17 - NOTICE OF INTERNAL PANEL REVIEW DECISION

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Notice requirements.
The
				health care insurer shall notify the grievant and provider of the internal
				panel's decision within 24 hours by telephone and in writing by mail or
				electronic communication sent within one day after the initial attempt to
				provide telephonic notice, unless earlier notice is required by the medical
				exigencies of the case.
B.
Contents of notice.
If the initial decision denying certification
				is upheld in whole or in part, then the panel's written notice shall contain:
(1) the names, titles and qualifying
				credentials of the persons on the internal review panel;
(2) a statement of the internal review
				panel's understanding of the nature of the grievance and all pertinent
				facts;
(3) a description of the
				evidence relied on by the internal review panel in reaching its
				decision;
(4) if an adverse
				determination is upheld based on a determination that the requested service is
				experimental, investigational or not medically necessary, then:
(a) clearly and completely explain why the
				requested health care service is not medically necessary, is experimental or
				investigational; a statement that the health care service is not medically
				necessary, is experimental or investigational will not be sufficient;
				and
(b) include a citation to the
				uniform standards relevant to the grievant's medical condition and an
				explanation of whether each supported or did not support the decision regarding
				a determination that the requested service is experimental, investigational, or
				medically necessary.
(5)
				if an adverse determination is upheld based on a lack of coverage, identify all
				health benefits plan provisions relied on in making the adverse determination,
				and clearly and completely explain why the requested health care service is not
				covered by any provision of the health benefits plan; a statement that the
				requested health care service is not covered by the health benefits plan will
				not be sufficient;
(6) if the
				service has already been provided, then include the date of service, the
				provider, the claim amount (if applicable), and a statement describing the
				availability, upon request, of the diagnosis code and its corresponding
				meaning, and the treatment code and its corresponding meaning;
(7) if the grievant is covered by the New
				Mexico Health Care Purchasing Act, then advise the grievant of the grievant's
				right to request review from and in the manner designated by an entity
				authorized to purchase health care benefits pursuant to the New Mexico Health
				Care Purchasing Act and that the entity must review the grievant's request
				before grievant can request an external review;
(8) if the adverse determination involved
				medical judgment, including a determination based on medical necessity,
				appropriateness, health care setting, level of care, effectiveness or that the
				requested health care service is experimental or investigational, notice of the
				grievant's right to request external review by an IRO within four months,
				including the address and telephone number of the MHCB, a description of all
				procedures necessary to pursue an IRO external review, copies of any forms
				required to initiate an IRO external review; or
(9) if the adverse determination did not
				involve medical judgment, notice of the grievant's right to request external
				review by the superintendent and copies of any forms required to initiate an
				external review by the superintendent.