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
Universal Citation: 11 NM Admin Code 11.4.7.12
Current through Register Vol. 35, No. 18, September 24, 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.
B. Inpatient admission review
(1) For every inpatient
admission the following information shall be provided to the WCA or its
contractor at least 48 hours prior to the admission or before the close of the
next business day after any emergency admission:
(a) worker's/patient's name;
(b) worker's/patient's social security
number;
(c) worker's/patient's
employer;
(d) employer's insurance
carrier or third party administrator and a statement of whether they have
authorized the admission;
(e) date
of injury/onset of symptoms;
(f)
admitting diagnosis, including primary, secondary, and tertiary, if
any;
(g) planned treatment(s) and
procedures;
(h) planned date of
admission; and
(i) proposed length
of stay.
(2) For planned
or elective hospital admissions any practitioner ordering the admission of a
worker for evaluation or treatment of their injury or occupational disease
disablement shall report the admission to the WCA.
(3) For emergency hospital admissions, the
hospital shall report the admission to the WCA.
C. Case management
(1) Referral process
(a) Any party may refer a claim to the WCA
for case management by the WCA or its contractor, if any, by submitting the
appropriate form to the WCA medical cost containment bureau. The form is
located on the agency website.
(b)
A WCA judge may refer a claim for case management by submitting a written
referral to the medical cost containment bureau and with a copy placed in the
court file.
(c) Within 20 days of
receiving a referral and all supporting documentation, the medical cost
containment bureau shall notify the parties and the judge, if any, of its
decision either accepting or denying the referral. The medical cost containment
bureau may assign approved cases to the WCA's contractor.
(d) Any party who objects to the decision of
the medical cost containment bureau shall notify the WCA of its objection by
filing an application to the director not later than 15 days from service of
the decision.
(2)
Procedures
(a) The WCA will consider the
following factors when determining eligibility of a case referred for case
management:
(i) severe or complex injury
including total loss of limb/amputation, severe injury to multiple body parts
or limbs, severe burns over a large part of body, traumatic brain injury,
spinal cord injury, reflex sympathetic dystrophy/complex region pain
syndrome;
(ii) language barrier,
including hearing impairment;
(iii)
a record or pattern of non-compliance with prescribed treatment, care plan or
medical appointments;
(iv) multiple
health care providers, including providers of different disciplines, requiring
coordination between them;
(v)
inpatient admission lasting longer than five days or multiple admissions or
emergency room visits;
(vi) failure
to reach maximum medical improvement after one year from the date of
injury;
(vii) psychological issues
that complicate provision of services; and
(viii) any other reasonable criteria as
approved by the director.
(b) The WCA will monitor case management
services to ensure progress pursuant to Section
52-4-3 NMSA 1978. The WCA may
terminate or reassign services as it deems appropriate with notice to the
parties.
(c) The contractor shall
have the right to contact the worker, insurer, third party administrator, legal
representatives, and all HCPs involved in the case. The contractor shall give
reasonable notice and an opportunity to the worker or his or her representative
to be present during, or to participate in, any and all contacts by the case
manager.
(d) The contractor
providing case management services may help coordinate services by bringing
treatment options or return to work opportunities to the attention of the
health care provider.
(e) The
contractor shall provide status reports to the WCA as directed, with copies to
the parties identified in the initial assignment.
D. Utilization review
(1) Referral process
(a) Any party may refer a claim to the WCA
for utilization review by the WCA or its contractor, if any, by submitting the
appropriate form to the WCA medical cost containment bureau. The form is
located on the agency website.
(b)
A utilization review request for pre-admission review of hospital admissions,
except for emergency services, shall also follow this same referral and
procedural process.
(c) Within 20
days of receiving a referral and all supporting documentation, the medical cost
containment bureau shall notify the parties of its decision either accepting or
denying the referral. The medical cost containment bureau may assign approved
cases to the WCA's contractor.
(d)
Any party who objects to the decision of the medical cost containment bureau
shall notify the WCA of its objection by filing an application to the director
not later than 15 days from service of the decision.
(2) Procedures
(a) Utilization review shall consider only
the medical reasonableness, clinical necessity, efficiency and quality of the
treatment under review.
(b) Only
one treatment is appropriate for utilization review.
(c) Utilization review shall not include
issues of compensability, including:
(i) the
causal relationship between the treatment under review and the worker's
work-related injury;
(ii) whether
the worker is disabled; and
(iii)
whether the worker is at maximum medical improvement.
(d) If the medical cost containment bureau or
its contractor requests additional information, the parties shall provide the
requested information within 15 days. The WCA shall issue its utilization
review decision within 60 days of receiving all necessary
documentation.
(e) The WCA in its
sole discretion may assign a claim to its contractor for peer review. Peer
review shall only be conducted by a licensed healthcare provider who is in a
similar field or equivalent discipline as the provider whose service is being
reviewed. Peer review shall be independent and the physician or health care
provider should not have prior involvement in the worker's care or
treatment.
(f) The medical cost
containment bureau shall communicate the utilization review findings in writing
with a copy to all parties. The WCA may adopt the findings of its contractor
after utilization review.
(g) Any
party who objects to the utilization review findings shall file an application
to director within 15 days from service of the utilization review findings. If
an application is not filed within 15 days, the utilization review findings
shall become binding on the parties.
(h) The director may set a utilization review
matter for hearing. An order issued by the director after hearing or receipt of
an application to director is final and binding on the parties.
Disclaimer: These regulations may not be the most recent version. New Mexico may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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