Current through Register Vol. 35, No. 18, September 24, 2024
A.
Grievant's rights.
(1) Following the IRO's decision, the MHCB
shall notify the grievant that if the grievant is dissatisfied with the IRO's
decision, the grievant may request a hearing from the superintendent within 20
days of the IRO decision. MHCB will provide the grievant with all forms
necessary to request a hearing by the superintendent.
(2) Any grievant whose adverse determination
grievance involved a rescission of coverage or did not involve medical judgment
may request a hearing by the superintendent within four months of receiving the
health care insurer's internal decision. The health care insurer will provide
the grievant will all forms necessary to request a hearing by the
superintendent.
B.
Review of request for hearing. Upon receipt of a request for a
hearing, the superintendent will review the request and may grant a hearing if
the following criteria are met:
(1) the
grievant has exhausted the internal review process or is not required to
exhaust the internal review process and, if applicable, the external IRO review
process;
(2) the grievant has
timely requested review by the superintendent;
(3) the grievant has provided a signed
release and all forms and documents required to process the request,
and
(4) the health care service
that is the subject of the request reasonably appears to be a covered benefit
under the applicable health benefits plan.
C.
Request incomplete. If the
request for an external hearing is incomplete, MHCB staff shall immediately
notify the grievant and request that the grievant submit the information
required to complete the request for external review within a specified period
of time. If the grievant fails to provide the required information within the
specified time, the request will be deemed to not meet the criteria prescribed
by this rule.
D.
Request does
not meet criteria. If the request for an external hearing does not meet
the criteria prescribed by this rule, MHCB staff shall so inform the
superintendent. The superintendent shall notify the grievant and the health
care insurer that the request does not meet the criteria for external hearing
and is thereby denied.
E.
Request meets criteria. If the request for external review is
complete and meets the criteria prescribed by this rule, MHCB staff shall so
inform the superintendent. The superintendent shall notify the grievant and the
health care insurer that the request meets the criteria for external review and
that an informal hearing pursuant to Section
59A-4-18 NMSA
1978 and this rule has been set to consider the request. Prior to the hearing,
insurance division staff shall attempt to informally resolve the grievance in
accordance with Section
12-8-10
NMSA 1978.
F.
Notice of
hearing. For an expedited review, the notice of hearing shall be given
to the grievant, the provider and the health care insurer telephonically. For a
standard review, notice of the hearing shall be provided telephonically, and in
writing by mail or electronically no less than 10 days prior to the hearing
date. The notice shall state the date, time, and place of the hearing and the
matters to be considered and shall advise the parties of their respective
rights. The superintendent shall not unreasonably deny a request for
postponement of the hearing made by the grievant or the health care insurer. If
the grievant wishes to supply supporting documents or information subsequent to
the filing of the request for a hearing with the superintendent, the timeframes
for the hearing shall be extended up to 90 days from the receipt of the request
or until the grievant submits all supporting documents, whichever occurs
first.
G.
Timeframe for
completion of hearing. The superintendent shall complete the review
within the following timeframes:
(1) an
expedited review shall be completed no later than 72 hours after receipt of the
complete request, or as required by the exigencies of the matter under review;
and
(2) a standard review shall be
completed within 45 days after receipt of the complete request.
H.
Conduct of
hearing. The superintendent may designate a hearing officer who shall be
an attorney licensed to practice in New Mexico. The hearing may be conducted by
telephone conference call, video conferencing, or other appropriate technology
at OSI's expense.
(1)
Co-hearing
officers. The superintendent may designate two ICOs who shall be
licensed health care professionals and who shall maintain independence and
impartiality in the process. If the superintendent designates two ICOs, at
least one of them shall practice in a specialty that would typically manage the
case that is the subject of the grievance.
(2)
Powers. The superintendent
or attorney hearing officer shall regulate the proceedings and perform all acts
and take all measures necessary or proper for the efficient conduct of the
hearing. The superintendent or attorney hearing officer may:
(a) require the production of additional
records, documents and writings relevant to the subject of the
grievance;
(b) exclude any
irrelevant, immaterial or unduly repetitious evidence; and
(c) if the grievant or health care insurer
fails to appear, proceed with the hearing or adjourn the proceedings to a
future date, giving notice of the adjournment to the absent party.
(3)
Staff
participation. Staff may attend the hearing, ask questions and otherwise
solicit evidence from the parties, but shall not be present during
deliberations among the superintendent or his designated hearing officer, and
any ICOs.
(4)
Testimony. Testimony at the hearing shall be taken under oath. The
superintendent or hearing officers may call and examine the grievant, the
health care insurer and other witnesses.
(5)
Hearing recorded. The
hearing shall be stenographically recorded at OSI's expense.
(6)
Rights of parties. Both the
grievant and the health care insurer have the right to:
(a) attend the hearing; the health care
insurer shall designate a person to attend on its behalf, and the grievant may
designate a person to attend on grievant's behalf if the grievant chooses not
to attend personally;
(b) be
assisted or represented by an attorney or other person;
(c) call, examine and cross-examine
witnesses; and
(d) submit to the
ICO, prior to the scheduled hearing, in writing, additional information that
the ICO must consider when conducting the internal review hearing, and require
that the information be submitted to the health care insurer and the MHCB
staff.
(7)
Stipulation. The grievant and the health care insurer shall each
stipulate on the record that the hearing officers shall be released from civil
liability for all communications, findings, opinions and conclusions made in
the course and scope of the external review.
I.
New Mexico health care plan
representative. If a grievant is insured pursuant to the New Mexico
Health Care Purchasing Act and the grievant requests a hearing, if a
representative from the self-insured plan is not present at any pre-hearing
conference or at the hearing required by OSI, the health care insurer will be
deemed to speak on behalf of the self-insured plan.
