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. 6, March 26, 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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