New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 308 - MANAGED CARE PROGRAM
Part 15 - GRIEVANCES AND APPEALS
Section 8.308.15.11 - GENERAL INFORMATION ON MCO MEMBER GRIEVANCES AND APPEALS PROCESSES
Universal Citation: 8 NM Admin Code 8.308.15.11
Current through Register Vol. 35, No. 18, September 24, 2024
A. Upon a member's enrollment:
(1) the MCO shall provide to the
member and his or her authorized representative at no cost a written
description of its member grievance and member expedited and standard appeal
system and member expedited appeal system procedures and processes;
(2) the MCO will promptly provide in writing
to each member, his or her authorized representative any changes to these
procedures and processes. The description shall include:
(a) information on how the member or his or
her authorized representative or authorized provider can request a MCO
expedited or standard appeal, or how the member or his or her authorized
representative can file a MCO member grievance; and the resolution processes
for each;
(b) time frames for each
step of the MCO member grievance and the MCO expedited and standard member
appeal processes through to their final resolution;
(c) a description of how a MCO member's
grievance or MCO expedited or standard member appeal is resolved;
(d) information that the MCO may have only
one level of appeal for the member;
(e) in the case of a MCO that fails to adhere
to the time frames for each step of its procedures and process, the member or
his or her authorized representative is deemed to have exhausted the MCO's
expedited or standard member appeal process and the member or his authorized
representative may request a HSD expedited or standard administrative
hearing.
(f) The MCO shall
designate a specific employee as its member grievance and appeal manager with
the authority to:
(i) administer the policies
and procedures for resolution of a MCO member grievance and a MCO expedited or
standard member appeal;
(ii) review
patterns and trends in MCO member grievances, and MCO expedited or standard
member appeals; and
(iii) ensure
that punitive or retaliatory action is not taken against any member or his or
her authorized representative that files a MCO member grievance or any member,
his or her authorized representative or the authorized provider who requests a
MCO expedited or standard member appeal.
(g) Prior to the MCO taking an adverse
action, in order to avoid incomplete information during the MCO expedited or
standard member appeal process or the HSD expedited or standard administrative
hearing process, the MCO must contact the requesting provider for more
information or justification regarding the request if lack of information or
justification is likely to lead to the adverse action.
B. MCO member grievance and MCO expedited and standard member appeal rights and responsibilities:
(1)Standing to file a MCO member grievance:
(a)The member or his or her authorized
representative may file a MCO member grievance concerning dissatisfaction with
the MCO's operation.
(b) The member
or his or her authorized representative may choose a relative, friend or other
spokesperson to advocate or assist him or her through the MCO member grievance
process; however, the spokesperson is limited to a supporting role and cannot
act on behalf of the member or his or her authorized representative. The member
or his or her authorized representative must provide the MCO a signed
release-of-information in order for the designated spokesperson to have access
to information to aid the spokesperson to assist or advocate for the member or
his or her authorized representative during the MCO's member grievance process.
A member or his or her authorized representative may elect not to sign such a
release, but utilize the spokesperson during the MCO member grievance
process.
(2) The member
or his or her authorized representative may have legal counsel assist him or
her during the MCO member grievance process.
(3) Grievance: A member or his or her
authorized representative shall have the right to file a grievance with his or
her MCO to express dissatisfaction about any matter or aspect of his or her
MCO's operation other than an adverse benefit determination without time
limitations. A MCO member grievance final decision cannot be appealed through
the MCO member appeal process or the HSD administrative hearing process. If the
member or his or her authorized representative or the authorized provider
wishes to appeal an intended or taken adverse action against the member, the
member, his or her authorized or the authorized provider must comply with all
requirements to request a MCO expedited or standard member appeal including
applicable time frames in which to request a MCO expedited or standard member
appeal. A member may file both a MCO member grievance and a MCO expedited or
standard member appeal, but the MCO appeal must meet all applicable filing time
requirements which are not changed by the filing of a grievance.
(a) The member or his or her authorized
representative may file a MCO member grievance either orally or in writing in
accordance with the MCO's procedures and processes.
(b) The member or his or her authorized
representative may file a MCO member grievance at any time when he or she
wishes to register his or her dissatisfaction.
(c) The MCO will provide the member or his or
her authorized representative with its resolution to the member's grievance
within the time frame specified in the MCO's medicaid managed care services
agreement.
(4)
MCO
expedited or standard member appeal: A member or his or her authorized
representative or the authorized provider has the right to request a MCO
standard member appeal orally and in writing in accordance with his or her MCO
procedures within 60 calendar days of the date of notice of an intended or
taken adverse action. If the request is orally, it must be followed up in
writing within 13 calendar days of the oral request. A member, his or her
authorized representative or authorized provider has the right to request a MCO
expedited member appeal orally or in writing in accordance with the member's
MCO procedures within 60 calendar days of the date of the notice of an intended
or taken adverse action.
(a) The member or
his or her authorized representative or the authorized provider may have legal
counsel to assist him or her during the MCO expedited or standard member appeal
process.
(b) Standing to request a
MCO expedited or standard member appeal:
(i)The member or his or her authorized
representative may request a MCO expedited or standard member appeal concerning
his or her disputed benefit.
(ii)
The member, his or her authorized representative or authorized provider may
choose a relative, friend or other spokesperson to advocate or assist him or
her through the MCO expedited or standard member appeal process; however, the
spokesperson is limited to a supporting role and cannot act on behalf of the
member or his or her authorized representative. The member or his or her
authorized representative must provide the MCO a signed release-of-information
in order for a designated spokesperson to have access to information to aid the
spokesperson to assist and advocate for the member or his or her authorized
representative during the MCO expedited or standard member appeal
process.
(c) If a member
or his or her authorized representative or authorized provider elects to
request a continuation of the disputed current benefit, the member, his or her
authorized representative or authorized provider must request a MCO expedited
or standard member appeal and also request a continuation of the disputed
benefit within 10 calendar days of the mailing of the MCO's notice of action or
before the expected effective date of the MCO's proposed adverse action benefit
determination, whichever is later. When the mailing date is disputed or there
is a discrepancy between the mailing date and the postmarked date, the
postmarked date will prevail. The member or his or her authorized
representative or authorized provider does not have the right to request a HSD
expedited or standard administrative hearing related to a value-added services
offered by the MCO. If the member or his or her authorized representative or
authorized provider chooses to request a MCO expedited or standard member
appeal, the following apply.
(i) The member,
his or her authorized representative or authorized provider cannot request
separate appeals. Only one appeal can be filed.
(ii) If the MCO upholds its adverse action,
regardless of who requested the MCO expedited or standard member appeal, the
MCO expedited or standard member appeal process is considered exhausted and the
member or his or her authorized representative may request a HSD expedited or
standard administrative hearing concerning his or her disputed benefit. Once
the member or his or her authorized representative requests a HSD expedited or
standard administrative hearing, he or she is referred to as the claimant. The
authorized provider is not eligible to request a HSD expedited or standard
administrative hearing on the disputed benefit, unless the provider has been
designated as the member's authorized representative. See 8.352.2 NMAC for a
detailed description of the HSD expedited and standard administrative hearing
processes.
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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