Current through Register Vol. 35, No. 18, September 24, 2024
A.
Utilization management program: The health care insurer through its MHCP shall
establish and implement a comprehensive utilization management program to
monitor access to and appropriate utilization of health care services. The
program shall be under the direction of a medical director responsible for the
medical services provided by the MHCP in New Mexico and who is a licensed
physician in New Mexico, and shall be based on a written plan that is reviewed
at least annually. At a minimum, the plan shall identify the following:
(1) scope of utilization management
activities;
(2) procedures to
evaluate clinical necessity, access, appropriateness, and efficiency of
services;
(3) mechanisms to detect
underutilization and overutilization;
(4) clinical review criteria and protocols
used in decision-making;
(5)
mechanisms to ensure consistent application of review criteria and uniform
decisions;
(6) development of
outcome and process measures for evaluating the utilization management program;
and
(7) a mechanism to evaluate
member and provider satisfaction with the complaint and appeals systems set
forth at 13.10.17 NMAC; such evaluation shall be coordinated with the
performance monitoring activities conducted pursuant to the continuous quality
improvement program to include care coordination between utilization
management, case management and disease management services as set forth in
13.10.22.10 NMAC.
B.
Utilization management determinations shall be based on written clinical
criteria and protocols developed with involvement from practicing physicians
and other health professionals and providers within the MHCP's net network.
These criteria and protocols shall be periodically reviewed and updated, and
shall, with the exception of internal or proprietary quantitative thresholds
for utilization management, be readily available, upon request, to affected
providers and covered persons. The MHCP shall have the burden of showing that
information requested by affected providers or covered persons is in fact
proprietary. Nothing in this section shall be construed to prevent a MHCP from
incorporating into its clinical protocols criteria from outside
sources.
C.
Utilization
management staff availability:
(1) A
registered professional nurse or physician shall be immediately available by
telephone seven days a week, 24 hours a day, to render utilization management
determinations for providers.
(2)
The MHCP shall provide all covered persons and providers with a toll-free
telephone number by which to contact utilization management staff on at least a
five-day, 40 hours a week basis. The MHCP may provide a separate telephone
number for covered persons and for providers.
(3) All covered persons must have immediate
telephone access seven days a week, 24 hours a day, to their primary care
physician or the physician's authorized on-call back-up provider. When these
providers are unavailable, a registered nurse or physician on the utilization
management staff must be available to respond to inquiries concerning emergency
or urgent care.
D.
Utilization management determinations:
(1) All determinations to authorize an
admission, service, procedure or extension of stay shall be rendered by either
a physician, registered professional nurse, or other qualified health
professional.
(2) All
determinations to deny or limit an admission, service, procedure or extension
of stay shall be rendered by a physician, either after application of uniform
criteria established by the plan in consultation with specialists acting within
the scope of their license or after consultation with specialists acting within
the scope of their license. The physician shall be under the clinical direction
of the medical director responsible for medical services provided to the MHCP's
New Mexico covered persons. Such determinations shall be made in accordance
with clinical and medically necessary criteria developed pursuant to Subsection
A of 13.10.22.9 NMAC and the evidence of coverage.
(3) All determinations shall be made on a
timely basis as required by the exigencies of the situation and in accordance
with sound medical principles, which, in any event, shall not exceed 24 hours
for emergency care and seven days for all other determinations. If the MHCP is
unable to complete a referral within ten days due to unforeseen circumstances,
the MHCP shall inform the covered person in writing about the reasons for the
delay and when a decision may be expected.
(4) A MHCP may not retroactively deny
reimbursement for a covered service provided to a covered person by a provider
who relied upon the verbal or written authorization of the MHCP or its agents
prior to providing the service to the covered person, except in those cases
where there was material misrepresentation or fraud. Retroactive reimbursement
for a covered service shall not be denied when the covered person provides
authorization information, such as a MHCP referral number, directly to the
provider, except in those cases where there was material misrepresentation or
fraud.
(5) An enrollee must receive
a written notice of all determinations to deny coverage or authorization for
health care services, which shall contain the reasons why coverage or
authorization was denied, and which shall be subject to review in accordance
with the specific grievance procedures outlined in 13.10.17 NMAC. The written
notice shall advise the covered person that review of the MHCP's denial of
coverage or authorization is available. In addition, the notice shall describe
the procedures necessary for commencing an internal review as outlined in
13.10.17 NMAC.
E.
Accreditation by nationally recognized accrediting entity. Nothing in
this section shall prohibit a MHCP from submitting accreditation by a
nationally recognized accrediting entity as evidence of compliance with the
requirements of this section. In those instances where a MHCP seeks to meet the
requirements of this section through accreditation by a private accrediting
entity, the MHCP shall submit to the division the following information:
1) current standards of the private
accrediting entity in order to demonstrate that the entity's standards meet or
exceed the requirements of this rule;
2) documentation from the private accrediting
entity showing that the MHCP has been accredited by the entity; and
3) a summary of the data and information that
was presented to the private accrediting entity by the MHCP and upon which
accreditation of the MHCP was based. A MHCP accredited by the private
accrediting entity that has submitted all of the requisite information to the
division may then be deemed by the superintendent to have met the requirements
of the relevant provisions of this section where comparable standards exist,
provided that the private accrediting entity from which the MHCP obtained
accreditation is recognized and approved by the superintendent.
