New Mexico Administrative Code
Title 13 - INSURANCE
Chapter 10 - HEALTH INSURANCE
Part 16 - PROVIDER GRIEVANCES
Section 13.10.16.8 - GENERAL RULES

Universal Citation: 13 NM Admin Code 13.10.16.8

Current through Register Vol. 35, No. 18, September 24, 2024

A carrier shall adopt and implement a provider grievance plan that complies with this rule. This rule does not preclude a carrier and provider from addressing or resolving a concern through any other process agreed on between them, but no such alternative process shall preclude a provider from presenting a grievance through a process that complies with this rule.

A. Allowed grievances. At a minimum, a carrier's provider grievance plan shall allow a provider to present any concern regarding:

(1) credentialing deadlines;

(2) claim payment amount or timing;

(3) claim submission requirements or compliance;

(4) network adequacy, including participation determinations based on network composition;

(5) network composition including provider qualifications;

(6) utilization management practices;

(7) provider contract construction or compliance;

(8) patient care standards or access to care;

(9) surprise billing reimbursement amount, rate or timing;

(10) termination;

(11) operation of the plan including compliance with any law enforceable by the superintendent, or of any directive of the superintendent; or

(12) Discrimination.

B. Timeline to file. A provider grievance plan shall allow a provider at least 90 days from the incident that is the subject of the grievance, to file a grievance.

C. Filing procedures and response. A provider grievance plan shall allow a provider to submit a written grievance electronically or manually. A carrier shall send a written acknowledgment of the grievance to the provider within five days of its receipt of the grievance using the provider's preferred communication method.

D. Point of contact. A provider grievance plan may require the submission of a complaint to a designated contact, as specified in the carrier's provider manual which shall identify the designated contact by name or position and provide a valid mailing address, phone number, and email address for the designated point of contact.

E. Request for supplemental information. A provider grievance plan may allow a carrier to request supplemental information pertinent to the resolution of a grievance from the provider. Any such request shall be made within 10 days of the carrier's receipt of a grievance, and shall require the provider to submit the requested supplemental information within the next 10 days.

F. Review panel. A provider grievance plan shall, at a minimum, require a carrier to form a review panel comprised of multiple members, at least one of whom is in a position of authority over the carrier operations that are the subject of a grievance. The review panel shall be responsible for reviewing and deciding the provider's grievance. If the grievance raises a quality-of-care concern the panel must include a New Mexico-licensed medical professional who practices in the general area of concern. A New Mexico-licensed physician shall be included on a review panel considering complex quality-of-care concerns. No person with a conflict of interest shall participate in a decision to resolve a grievance. Employment with the carrier, standing alone, does not present a conflict of interest.

G. Response. A provider grievance plan shall require a carrier to deliver a written response, to a grievance using the provider's preferred method of communication within 45 days of the later of receipt of the grievance, receipt of supplemental information requested to resolve the grievance, or the due date for submission of any requested supplemental information. The response shall include:

(1) the name(s), title(s), and qualification(s) of each person who participated in the grievance decision;

(2) a statement of issue(s) decided and of the ultimate decision(s);

(3) a clear and complete explanation of the rationale for the decision and a summary of the evidence relied upon to support the decision;

(4) a summary of any proposed remedial action; and

(5) information on the provider's appeal rights.

H. Extension of deadlines. If confirmed in a documented communication a carrier and provider may agree to extend any deadline imposed by this rule or a provider grievance plan.

I. Presentation of evidence. A provider grievance plan shall include reasonable procedures by which a provider may present oral or documentary evidence to the assigned grievance panel.

J. Bundled or group grievances. A provider grievance plan shall allow a provider to submit multiple related grievances simultaneously provided the grievances are not unduly duplicative or repetitive, and for a group of providers to assert a single grievance on behalf of multiple providers.

K. Non-participating providers. A carrier's provider grievance plan shall allow a non-participating provider to submit a grievance described in Paragraphs (1), (2), (4), (5), (6), (9) or (12) of Subsection A of this section. The grievance must assert and explain that the carrier's act or practice directly impacted the non-participating provider or a patient of that provider.

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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