Current through Register Vol. 35, No. 18, September 24, 2024
A.
For covered
persons/grievants.
A health care insurer shall:
(1) include a clear and concise summary of
the grievance procedures, both internal and external, in boldface type in all
handbooks or evidences of coverage, issued to covered persons, along with a
link to the full version of the grievance procedures, as found on the OSI
website;
(2) when the health care
insurer makes either an initial or final adverse determination or an
administrative decision, provide the following to a covered person, that
person's authorized representative or a provider acting on behalf of a covered
person:
(a) a concise written summary of its
grievance procedures;
(b) a copy of
the applicable grievance forms;
(c)
a link to the full version of the grievance procedures, as found on the OSI
website; and
(d) a toll-free
telephone number, facsimile number, e-mail and mailing addresses of the health
care insurer's consumer assistance office and for the MHCB.
(3) notify covered person that a
representative of the health care insurer and the MHCB are available upon
request to assist covered person with grievance procedures by including such
information and a toll-free telephone number for obtaining such assistance in
the enrollment materials and summary of benefits issued to covered
person;
(4) make available on its
website or upon request, consumer education brochures and materials developed
and approved by the superintendent in consultation with the health care
insurer;
(5) provide notice to
covered person in a culturally and linguistically appropriate manner as defined
in Subsection H of
13.10.17.7
NMAC;
(6) provide continued
coverage for an approved on-going course of treatment pending the final
determination on review;
(7) not
reduce or terminate an approved on-going course of treatment without first
notifying the grievant sufficiently in advance of the reduction or termination
to allow a covered person to request a review and obtain a final determination
on review of the proposed reduction or termination; and
(8) allow covered person in urgent care
situations and those receiving an on-going course of treatment that the health
care insurer seeks to reduce or terminate to proceed with an expedited IRO
review at the same time as the internal review process.
B.
For providers. A health care
insurer shall inform all providers of the grievance procedures and shall make
all necessary forms available upon request, including consumer education
brochures and materials developed or approved by the superintendent for
distribution. These items may be provided in paper format or
electronically.
C.
Special
needs. Information about grievance procedures must be provided in
accordance with the Americans with Disabilities Act,
42 U.S.C. Sections
12101, et seq.; the Patient
Protection and Affordable Care Act of 2010,
P.L.
111-152 as codified in the U.S.C.; and 13.10.13
NMAC, and MHCB, particularly 13.10.13.29 NMAC, Cultural and Linguistic
Diversity.
