Current through Register Vol. 35, No. 18, September 24, 2024
A. The MCO may not arbitrarily deny or reduce
the amount, duration, or scope of a required service solely because of
diagnosis, type of illness, or condition of the member.
B. The services supporting members with
ongoing or chronic conditions or who require long-term services and supports
must be authorized in a manner that reflects the member's ongoing need for such
services and supports.
C. Family
planning services are provided in a manner that protects and enables the
member's freedom to choose the method of family planning to be used consistent
with 42 CFR 441.20, family planning services.
D. The MCO must specify what constitutes
"medically necessary services" in a manner that:
(1) is no more restrictive than that used in
the New Mexico administrative code (NMAC) MAD rules, including quantitative and
non-quantitative treatment limits, as indicated in state statutes and rules.
The state plan, and other state policy and procedures; and
(2) addresses the extent to which the MCO is
responsible for covering services that address:
(a) the prevention, diagnosis, and treatment
of a member's disease, condition, or disorder that results in health
impairments or disability;
(b) the
ability for a member to achieve age-appropriate growth and
development;
(c) the ability for a
member to attain, maintain, or regain functional capacity; and
(d) The opportunity for a member receiving
long-term services and supports to have access to the benefits of community
living, to achieve person-centered goals, and live and work in the setting of
his or her choice.
E. Authorization of services: For the
processing of requests for initial and continuing authorizations of services,
the MCO must:
(1) have in place, and follow,
written policies and procedures;
(2) have in effect mechanisms to ensure
consistent application of review criteria for authorization
decisions;
(3) consult with the
requesting provider for medical services when appropriate;
(4) authorize long term services and supports
(LTSS) based on an enrollee's current needs assessment and consistent with the
person-centered service plan;
(5)
assure that any decision to deny a service authorization request or to
authorize a service in an amount, duration, or scope that is less than
requested, be made by an individual who has appropriate expertise in addressing
the member's medical, behavioral health, or LTSS needs;
(6) notify the requesting provider, and give
the member written notice of any decision by the MCO to deny a service
authorization request, or to authorize a service in an amount, duration, or
scope that is less than requested and the notice must meet the requirements of
42 CFR 438.404, timely and adequate notice of adverse benefit determination;
and
(7) for drug items that require
prior authorization and drug items that are not on the MCO preferred drug list:
(a) provide a response by telephone or other
telecommunication device within 24 hours of a request for prior
authorization;
(b) provide for the
dispensing of at least a 72-hour supply of a covered outpatient prescription
drug in an emergency situation;
(c)
consider in the review process any medically accepted indications for the drug
item consistent with the American hospital formulary service drug information;
United States pharmacopeia-drug information (or its successor publications);
the DRUGDEX information system; and peer-reviewed medical literature as
described in section 1927(d)(5)(A) of the Social Security Act.
