New Mexico Administrative Code
Title 13 - INSURANCE
Chapter 10 - HEALTH INSURANCE
Part 17 - GRIEVANCE PROCEDURES
Section 13.10.17.22 - TIMEFRAMES AND PROCESSES FOR IRO REVIEW
Universal Citation: 13 NM Admin Code 13.10.17.22
Current through Register Vol. 35, No. 6, March 26, 2024
A. Type of IRO review. The IRO shall conduct either a standard or expedited review of the adverse determination, as required by the medical exigencies of the case.
(1) The IRO shall complete an expedited
external review and provide notice of its decision to the grievant, the
provider, the health care insurer, and the superintendent as required by the
medical exigencies of the case as soon as possible, but in no case later than
72 hours after appointment by the superintendent. If notice of the IRO's
decision is initially provided by telephone, written notice of the decision
shall be provided within 48 hours after the telephone notification.
(2) The IRO shall complete a standard
external review and provide written notice of its decision to the grievant, the
provider, the health care insurer and the superintendent within 20 days after
appointment by the superintendent.
B. Expedited IRO review, timeframe and process.
(1) In cases involving an
urgent care claim, the superintendent shall immediately upon receipt of a
request for an expedited IRO review send the grievant an acknowledgment that
the request has been received and send a copy of the request to the health
insurer.
(2) Within 24 hours or the
time limit set by the superintendent following receipt of a request for an
expedited IRO review from the superintendent, the health care insurer shall
complete a preliminary review of the matter to determine whether the request is
eligible for IRO review, and shall report immediately to OSI upon completion of
the preliminary review, as follows:
(a) the
grievant is or was a covered person in the health benefit plan at the time the
health care service was requested;
(b) the health care service that is the
subject of the request for IRO review reasonably appears to be a covered
benefit under the grievant's health benefit plan, but for a determination by
the health care insurer that the requested service is not covered because it is
experimental, investigational, or not medically necessary; and
(c) the grievant has or is not required to
exhaust the health carrier's internal grievance process.
(3) If the request is not complete, the
health care insurer shall inform the grievant, provider and the superintendent
telephonically and electronically and include in the notice what information or
materials are needed to make the request complete.
(4) If the request is not eligible for IRO
review, the health care insurer shall inform the grievant, provider and the
superintendent telephonically and electronically and include in the notice the
reasons for ineligibility and a statement that the health care insurer's
determination of ineligibility may be appealed to the superintendent.
(5) MHCB will confirm or obtain from the
grievant all information and forms required to process an expedited IRO review,
including the signed release form.
(6) Upon receipt of the health care insurer's
notice that a request is complete and eligible for IRO review and the
confirmation from MHCB, the superintendent will immediately randomly assign an
IRO from the superintendent's list of approved IROs to conduct an expedited
review, and shall:
(a) notify the health care
insurer of the name of the assigned IRO; and
(b) notify the grievant and the provider of
the name of the assigned IRO, that the health care insurer will provide to the
IRO all of the documents and information considered in making the adverse
determination, and that the grievant and provider may provide additional
information.
(7) The
superintendent may determine that a request is eligible for an expedited IRO
review notwithstanding a health care insurer's initial determination that the
request is incomplete or ineligible. In making an eligibility determination,
the superintendent's decision shall be made in accordance with the terms of the
grievant's health benefit plan.
(8)
MHCB will immediately provide to the assigned IRO and to the health care
insurer all information and forms obtained from the grievant, including a
signed release form.
(9) Within 24
hours from the date of the notice from the superintendent that the IRO has been
appointed, the grievant or the provider may also submit additional
documentation or information to the IRO; the IRO shall immediately forward any
documentation or information received from the grievant to the health care
insurer.
(10) Upon receipt of the
superintendent's notice that an IRO has been appointed, the health care insurer
shall within 24 hours provide to the assigned IRO, any information considered
in making the adverse determination, including, but not limited to:
(a) the summary of benefits;
(b) the complete health benefits plan, which
may be in the form of a member handbook/evidence of coverage;
(c) all pertinent medical records, internal
review decisions and rationales, consulting physician reports, and documents
and information submitted by the grievant and health care insurer;
(d) uniform standards relevant to the
grievant's medical condition that were used by the internal panel in reviewing
the adverse determination; and
(e)
any other documents, records, and information relevant to the adverse
determination and the internal review decision(s).
(11) Failure by the health care insurer to
provide the documents and information required by this rule within the time
specified shall not delay the conduct of the IRO external review. If the health
care insurer fails to provide the documents and information within the time
specified, the assigned IRO may terminate the review and make a decision to
reverse the adverse determination.
C. Standard IRO review, timeframe and process.
(1) Within one day after the
date of receipt of a request for an IRO review, the superintendent shall send
the grievant an acknowledgment that the request has been received and send a
copy of the request to the health insurer.
(2) Within five days following the receipt of
the IRO review request from the superintendent, the health insurer shall
complete a preliminary review of the request to determine whether the request
is eligible for IRO review, as follows:
(a)
the grievant is or was a covered person in the health benefit plan at the time
the health care service was requested or, in the case of a retrospective
review, was a covered person in the health benefit plan at the time the health
care service was provided;
(b) the
health care service that is the subject of the request for IRO review
reasonably appears to be a covered service under the grievant's health benefit
plan, but for a determination by the health care insurer that the requested
health care service is not covered because it is experimental, investigational,
or not medically necessary;
(c) for
experimental or investigational adverse determinations, the grievant's treating
physician certified, in writing, that one of the following applies:
(i) standard health care services or
treatments have not been effective in improving the condition of the
grievant;
(ii) standard health care
services or treatments are not medically appropriate for the
grievant;
(iii) there is no
available standard health care service or treatment covered by the health
benefits plan that is more beneficial than the recommended or requested health
care service or treatment;
(iv) the
health care service or treatment requested is likely to be more beneficial to
the grievant, in the physician's opinion, than any available standard health
care services or treatments; or
(v)
the grievant's treating physician, who is licensed, board certified or board
eligible to practice in the area of medicine appropriate to treat the
grievant's condition, has certified in writing that scientifically valid
studies using accepted protocols demonstrate that the health care service or
treatment requested is likely to be more beneficial to the grievant than any
available standard health care services or treatments.
(d) the grievant has exhausted or is not
required to exhaust the health care insurer's internal grievance process;
and
(e) the grievant has provided
all the information and forms required to process an IRO review, including the
signed release form.
(3)
Upon completion of the preliminary review, the health care insurer shall notify
the superintendent and grievant in writing within one day whether:
(a) the request is complete; and
(b) the request is eligible for IRO
review.
(4) If the
request:
(a) is not complete, the health care
insurer shall inform the grievant and the superintendent in writing and include
in the notice what information or material are needed to make the request
complete; or
(b) is not eligible
for an IRO review, the health care insurer shall inform the grievant and the
superintendent in writing and include in the notice the reasons for its
ineligibility.
(5) The
notice of initial determination shall include a statement informing the
grievant that a health care insurer's initial determination of ineligibility
for IRO review may be appealed to the superintendent.
(6) The superintendent may determine that a
request is eligible for an IRO review notwithstanding a health care insurer's
initial determination that the request is ineligible and require that it be
referred to an IRO. In making an eligibility determination, the
superintendent's decision shall be made in accordance with the terms of the
grievant's health benefit plan.
(6)
Even after the superintendent assigns a grievance to an IRO for review, the
MHCB may attempt to resolve the grievance between the health care insurer and
the grievant. If the matter is successfully resolved, OSI will immediately
notify the IRO to terminate work.
D. Assignment of IRO by superintendent.
(1) Within one day of
receipt of a notice that the health care insurer has determined a request is
eligible for an IRO review, the superintendent shall:
(a) randomly assign an IRO from the
superintendent's list of approved IROs to conduct the review;
(b) notify the health care insurer of the
name of the assigned IRO;
(c)
notify the grievant in writing that the request is eligible for an IRO external
review, the name of the assigned IRO, and that the health care insurer will
provide all of the documents and information considered by the health care
insurer in making the adverse determination; and
(d) notify the grievant that the grievant may
submit in writing to the assigned IRO within five days following the date of
receipt of the notice, any additional information that the IRO shall consider
when conducting the review. The IRO is not required to, but may, accept and
consider additional information submitted after five days.
(2) If the adverse determination is based on
a determination that the requested service is experimental, investigational, or
not medically necessary, then the superintendent shall direct the IRO to
utilize a panel of appropriate clinical peer(s) of the same or similar
specialty as would typically manage the case being reviewed.
(3) Within one day after the receipt of the
notice of assignment by the superintendent to conduct the external review, the
assigned IRO shall select one clinical reviewer or for experimental or
investigational adverse determinations, three clinical reviewers to conduct the
external review.
(4) Within five
days following the notice of the assigned IRO, the health care insurer shall
provide to the assigned IRO all documents and any information considered in
making the adverse determination, including, but not limited to:
(a) the summary of benefits;
(b) the complete health benefits plan, which
may be in the form of a member handbook/evidence of coverage;
(c) all pertinent medical records, internal
review decisions and rationales, consulting physician reports, and documents
and information submitted by the grievant and health care insurer;
(d) uniform standards relevant to the
grievant's medical condition that were used by the internal panel in reviewing
the adverse determination; and
(e)
any other documents, records, and information relevant to the adverse
determination and the internal review decision(s).
(5) Failure by the health care insurer to
provide the documents and information required by this rule within the time
specified shall not delay the conduct of the external review. If the health
care insurer fails to provide the documents and information within the time
specified, the assigned IRO may terminate the review and make a decision to
reverse the adverse determination. Within one day after making such a decision,
the IRO shall notify the grievant, the provider, the health care insurer, and
the superintendent.
(6) If the
grievant provides additional supporting documents or information to the IRO:
(a) The IRO shall send any information
received from grievant to the health care insurer within one day.
(b) Upon receipt of such information, the
health care insurer may reconsider its adverse determination.
(7) If, upon such review, the
health care insurer reverses its prior decision, it shall within one day
provide written notification of its decision to the grievant, the provider, the
assigned IRO and the superintendent.
(a) If
the health care insurer reverses its prior decision, the assigned IRO shall
terminate its review upon receipt of the notice from the health care
insurer.
(b) Upon reversing its
prior decision, the health care insurer shall approve coverage for the health
care service subject to any applicable cost sharing including co-payments,
co-insurance and deductible amounts for which the grievant is
responsible.
(c) The health care
insurer shall compensate the IRO according to the published fee schedule
whenever the IRO review is terminated prior to completion.
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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