Current through Register Vol. 35, No. 18, September 24, 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.
B. HCP choice:
(1) Emergency care: The provision of
emergency medical care shall not be considered a choice of a treating HCP by
the employer or worker.
(2)
Selection of HCP:
(a) The employer shall
decide either to select the initial HCP or to permit the worker to select the
initial HCP. The decision made by the employer shall be made in writing to the
worker. Employer may communicate the decision to select the initial HCP or to
permit the worker the selection by any method reasonably calculated to notify
workers. The employer may use a wallet card, a poster stating the decision
posted with the WCA poster, a flyer inserted semi-annually with pay checks, or
any other method employer reasonably believes will be successful in alerting
the worker.
(b) If the decision of
the employer is not communicated in writing to the worker, then the medical
care received by the worker prior to written notification shall not be
considered a choice of treating HCP by either party.
(c) Medical treatment provided to the worker
prior to the employer's written communicated decision to either select the HCP,
or to permit the worker to select the HCP, shall be considered authorized
health care, the cost of which shall be borne by the employer.
(d) If a provider not licensed in New Mexico
treats a worker, the employer must, upon receipt of the initial billing from
that provider, either request approval of the out-of-state HCP pursuant to the
act, or immediately notify the worker in writing that the provider is not
acceptable pursuant to Section
52-4-1 NMSA
1978.
C.
Referrals by an authorized HCP:
(1) A
referral by an authorized HCP to another HCP shall be deemed a continuation of
the selection of the referring HCP.
(2) The 60 day effective period allowed in
Subsection B of Section
52-1-49 NMSA 1978, is not enlarged
by the HCP's referral.
D.
Notice of change of HCP:
(1) The 60 day period
of initial HCP choice shall run from the date of first treatment or examination
by, or consultation with, the initial HCP.
(2) The notice of change of HCP shall
provide:
(a) name, address and telephone
number of worker, employer and insurance carrier, if any;
(b) date and county of accident;
(c) nature of injury;
(d) the names, addresses and telephone
numbers of the current and proposed HCPs;
(e) the signature of the party requesting the
change of HCP; and
(f) the
following text: "your rights may be affected by your failure to respond to this
notice; if you need assistance and are not represented by an attorney, contact
an ombudsman of the WCA."
(3) After 50 days of the initial 60 day
period, the party denied the initial selection may give notice of change of
HCP.
E. Issuance of
notice of change: The party seeking the change of HCP shall issue a notice of
change of HCP. A copy of the notice shall be provided to the other party 10
days prior to provision of any medical treatment by the proposed HCP.
F. Effective date of notice of change:
(1) The notice of change shall be effective,
unless an objection is filed with the clerk within three days from receipt of
the notice of change. A copy of the notice of change shall be attached to any
objection filed with the clerk. If no objection is filed, the HCP declared on
the notice of change form shall be designated as the authorized treating HCP
and may begin treating the worker 11 days after issuance of the notice of
change.
(2) An objection can be
filed after the three day period, but any bills incurred for medical treatment
rendered after the effective date of the notice of change and prior to a ruling
by the judge on the objection shall be paid by the employer. A party required
to pay for medical treatment pursuant to this rule shall not be deemed to have
waived any objections to the reasonableness or necessity of the treatment
provided.
G.
Responsibility for payment of HCP services:
(1) The employer shall be responsible for all
reasonable and necessary medical services provided by an authorized HCP from
the date the notice of change is effective.
(2) The worker shall be responsible for any
medical services rendered by an unauthorized HCP.
(3) The designation of an authorized HCP
shall remain in effect until modified by agreement of the parties or by order
of the judge.
(4) Effective July 1,
2013, all medical services rendered pursuant to recommended treatment contained
in the most recent edition of the official disability guidelinesT (ODG) is
presumed reasonable and necessary; there is no presumption regarding any other
treatment.
H. Reasonable
and necessary disputes: Disputes concerning the reasonableness and necessity of
prescribed treatment may be brought before the administration pursuant to
11.4.7.11 NMAC.
I. Hearing on objection to notice of change:
If an objection to notice of change of HCP is filed with the clerk, the
objection shall be heard by the judge within seven days from the filing of the
objection. The judge may issue a minute order at the conclusion of the hearing
on the objection.
J. Request for
change of HCP: If a disagreement arises over the selection of a HCP, and the
parties cannot otherwise agree, a request for change of HCP must be submitted
to the clerk. The request for change of HCP may be submitted at any time,
including the initial 60 day period.
K. Request for change of HCP form:
(1) The request for change of HCP must state
the specific reasons for the requested change.
(2) The request for change of HCP may suggest
an alternative HCP's name.
L. Burden of proof: The applicant requesting
a change of HCP must prove the authorized HCP is not providing the worker
reasonable and necessary medical care. If the applicant fails to establish the
provision of medical care is not reasonable, the request for change shall be
denied.
M. Hearing on request for
change of HCP: The request for change of HCP disagreement shall be heard by the
judge within seven days from the filing of the request for change of HCP. The
judge may issue a minute order at the conclusion of the hearing on the request
for change.
