New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 308 - MANAGED CARE PROGRAM
Part 15 - GRIEVANCES AND APPEALS
Section 8.308.15.7 - DEFINITIONS
Current through Register Vol. 35, No. 18, September 24, 2024
A. "Administrative law judge (ALJ)" means the hearing officer appointed by the HSD fair hearings bureau (FHB) to oversee the claimant's administrative hearing process, to produce an evidentiary record and render a recommendation to the medical assistance division (MAD) director.
B. "Adverse action against a member" is when a HSD managed care organization (MCO) intends or has taken action against a member of his or her MCO as in one or more of the following situations.
C. "Adverse action against a provider" means when a MCO intends or has taken adverse action against a provider based on the MCO denial of the provider's payment, including a denial of a claim for lack of medical necessity or as not a covered benefit.
D. "Authorized provider" means the member's provider who has been authorized in writing by the member or his or her authorized representative to request a MCO expedited member appeal or a MCO standard member appeal on behalf of the member. An authorized provider does not have the full range of authority to make medical decisions on behalf of the member.
E. "Authorized representative" means the individual designated by the member or legal guardian to represent and act on the member's behalf.
F. "HSD expedited administrative hearing" means an expedited informal evidentiary hearing conducted by the HSD fair hearings bureau (FHB) in which evidence may be presented as it relates to an adverse action taken or intended to be taken, by the MCO. A member or his or her authorized representative may request a HSD expedited administrative hearing only after exhausting his or her MCO expedited or standard member appeal process and unless the request for a HSD expedited administrative hearing is because the MCO has denied the member's request for a member appeal to be expedited. See 8.352.2 NMAC for a detailed description of the HSD expedited administrative hearing process and Subsection B of 8.308.15.13 NMAC.
G. "HSD PASRR administrative hearing" means a HSD administrative hearing process which is an informal evidentiary hearing conducted by FHB in which evidence may be presented as it relates to an adverse action taken or intended to be taken by a MCO of a member's disputed PASRR determination, or a member's disputed transfer or discharge from a NF. See 8.354.2 NMAC for a detailed description of the HSD PASRR administrative hearing process.
H. "HSD standard administrative hearing" means an informal evidentiary hearing conducted by FHB in which evidence may be presented as it relates to an adverse action taken or intended to be taken, by the MCO. A member or his or her authorized representative may request a HSD standard administrative hearing only after exhausting his or her MCO expedited or standard member appeal process. See 8.352.2 NMAC for a detailed description of the HSD standard administrative hearing process.
I. "MAD" means the medical assistance division, which administers medicaid and other medical assistance programs under HSD.
J. "MAP" means the medical assistance programs administered under MAD.
K. "MCO" means the member's HSD contracted managed care organization.
L. "MCO expedited member appeal" means the process open to a member or his or her authorized representative or authorized provider when the member's MCO has taken or intends to take an adverse action against the member's benefit.
M. "MCO standard member appeal" means:
N. "MCO member grievance" means an expression of dissatisfaction by a member or his or her authorized representative about any matter or aspect of the MCO or its operation that is not included in the definition of an adverse action. A MCO member grievance final decision does not provide a member the right to request a HSD expedited or standard administrative hearing, unless the reason for the request is based on the assertion by the member or his or her authorized representative that the MCO failed to act within the MCO member grievance time frames.
O. "MCO provider appeal" means the process open to a provider requesting a review by the MCO of his or her payment, including denial of a claim for lack of medical necessity or as not a covered benefit.
P. "MCO expedited or standard member appeal final decision" means the MCO's final decision regarding a member's or his or her authorized representative's or authorized provider's request for a MCO expedited or standard member appeal of the MCO's adverse action it intends to take or has taken against its member.
Q. "MCO provider grievance" means an expression of dissatisfaction by a provider about any matter or aspect of the MCO or its operation that is not included in the definition of an adverse action. The MCO provider grievance final decision does not allow a provider to request a HSD provider administrative hearing.
R. "Member" means an eligible recipient enrolled in a MCO.
S. "Notice of action" means the notice of an adverse action intended or taken by the member's MCO.
T. "Provider" means a practitioner or entity which has delivered or intends to provide a service or item whether the provider is contracted or not contracted with the member's MCO at the time services or items are to be provided.
U. "Valued added services" means services offered by a MCO that are not part of the MCO's required benefit package. Disputes concerning value-added services are not eligible for a MCO appeal or a HSD administrative hearing.