New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 350 - RECONSIDERATION OF UTILIZATION REVIEW
Part 2 - RECONSIDERATION OF UTILIZATION REVIEW DECISIONS
Section 8.350.2.10 - RECONSIDERATION OF UTILIZATION REVIEW DECISIONS

Universal Citation: 8 NM Admin Code 8.350.2.10

Current through Register Vol. 35, No. 18, September 24, 2024

A provider who is dissatisfied with a medical necessity or LOC decision by MAD, its UR contractor or a MAD designee, can request reconsideration. An eligible recipient who is dissatisfied with a medical necessity or LOC decision by MAD, its UR contractor or a MAD designee, can request the provider to pursue reconsideration on his or her behalf.

A. Time constraints and submission requirements: Requests for reconsideration must be in writing and received by MAD, its UR contractor or a MAD designee within 30 calendar days after the date on the initial notice of action.

B. Requirement for filing an extension: MAD, its UR contractor or a MAD designee will accept a request for reconsideration filed up to 14 calendar days past the 30 calendar day limit if MAD finds that there was good cause for the provider's or the eligible recipient's failure to file a timely request. The provider or the eligible recipient must furnish written documentation of good cause. Good cause includes a death in the family, a disabling personal illness or another significant emergency or other exceptional circumstance.

C. Information required in the request for reconsideration: The request for reconsideration must include the following:

(1) reference to the challenged decision or action;

(2) basis for the challenge;

(3) copies of any document(s) pertinent to the challenged decision or action;

(4) copies of claim form(s) if the challenge involves a claim for payment which is denied due to an UR decision; and

(5) a statement that a reconsideration of the decision is requested.

D. Individuals conducting reconsideration review: Individuals employed by MAD, its UR contractor or a MAD designee who were not participants in the initial UR decision conduct the reconsideration review.

E. Information used in reconsideration process: MAD, its UR contractor or a MAD designee reviews the information and findings upon which the initial action was based and any additional information submitted to, or otherwise obtained by MAD, its UR contractor or a MAD designee. The information can include the following:

(1) case records and other applicable documents submitted to MAD, its UR contractor or a MAD designee by the provider when the request for services was initially submitted;

(2) findings of the reviewer resulting in the initial decision;

(3) complete record of the service(s) provided, including hospital or medical records; and

(4) additional documents submitted by the provider to support a reconsideration review.

F. Decision deadline: MAD, its UR contractor or a MAD designee performs the reconsideration and furnishes the reconsideration decision within 10 business days of receipt of the reconsideration request.

G. Notification of reconsideration decision: MAD, its UR contractor or a MAD designee gives the provider and the eligible recipient written notice of the reconsideration determination. If the decision is adverse to the eligible recipient, the notice also includes information on the eligible recipient's right to a HSD administrative hearing and timeframes to file for a hearing and request for a continuation of his or her current benefit.

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.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.