Current through Register Vol. 35, No. 18, September 24, 2024
A.
Right to
external review and scope. Every grievant who is dissatisfied with the
results of the internal review and reconsideration committee hearing of an
administrative decision shall have the right to request external review by the
superintendent.
B.
Exhaustion
of remedies. The superintendent may require the grievant to exhaust any
grievance procedures adopted by the health care insurer or an entity that
purchases health care benefits pursuant to the New Mexico Health Care
Purchasing Act, as appropriate, before accepting a grievance for external
review.
C.
Deemed
exhaustion. If exhaustion of internal reviews is required prior to
external review, exhaustion must be unnecessary and the internal reviews
process will be deemed exhausted if:
(1) the
health care insurer waives the exhaustion requirement; or
(2) the health care insurer is considered to
have exhausted the internal reviews process by failing to comply with the
requirements of the internal reviews process.
D.
Exception to exhaustion requirement.
(1) Notwithstanding Subsection C of
13.10.17.30 NMAC, the internal claims and reviews process will not be deemed
exhausted based on violations by the health care insurer that are de
minimus and do not cause, and are not likely to cause prejudice or
harm to the grievant, so long as the health care insurer demonstrates that the
violation was for good cause or due to matters beyond the control of the health
care insurer, and that the violation occurred in the context of an on-going,
good faith exchange of information between the plan and the grievant. This
exception is not available if the violation is part of a pattern or practice of
violations by the health care insurer.
(2) The grievant may request a written
explanation of the violation from the health care insurer, and the health care
insurer must provide such explanation within 10 days, including a specific
description of its bases, if any, for asserting that the violation should not
cause the internal claims and reviews process to be deemed exhausted. If an
external reviewer or a court rejects the grievant's request for immediate
review on the basis that the health care insurer met the standards for the
exception under Paragraph (1) of Subsection D of 13.10.17.30 NMAC, the grievant
has the right to re-submit and pursue the internal review of the claim. In such
a case, within a reasonable time after the external reviewer or court rejects
the claim for immediate review (not to exceed 10 days), the health care insurer
shall provide the grievant with notice of the opportunity to re-submit and
pursue the internal review of the claim. Time periods for re-filing the claim
shall begin to run upon grievant's receipt of such notice.
