Current through Register Vol. 35, No. 18, September 24, 2024
A.
General Reconsideration
Process: Medicaid providers who disagree with an audit settlement can
submit a written request for a reconsideration to the New Mexico Medical
Assistance Division (MAD) within thirty (30) calendar days of the date on the
notice of final settlement. The written request may be submitted by facsimile
or by U.S. mail but not by electronic mail. The written request must be
received by MAD no later than the thirtieth day from the date of the notice.
Filing of a request for reconsideration does not affect the imposition of the
final settlement.
(1)
Information
Included in the Request: The written request for reconsideration must
identify each point on which the provider takes an issue with the audit agent
and include all documentation, citations of authority, and arguments on which
the request is based. Any point or issue not raised in the original request for
reconsideration may not be raised later and will not be considered in the final
decision of the reconsideration.
(2)
Audit Agent Response: The
written request and supporting materials is forwarded to the audit agent for
reconsideration. The audit agent must file a response with MAD within thirty
(30) calendar days of the receipt of the request and supporting material from
MAD.
(3)
Submission of
Additional Material: MAD forwards the audit agent's response to the
provider. Additional material from the audit agent or the provider must be
received by MAD within fifteen (15) calendar days of the date the response was
forwarded to the provider. Any additional information, the request for
reconsideration and supporting documentation, and the audit agent's response
constitute final submittal. The packet containing the final submittal is
provided to the MAD Deputy Director for final submittal by the responsible
bureau for program reimbursement.
(4)
Decision by MAD: The Deputy
Director may call on all information and call on all expertise he/she believes
is necessary to decide the issue. The Deputy Director makes a determination and
submits a written copy of his/her findings to each party within forty-five (45)
calendar days of the date of final submittal to the MAD Director. The decision
may be sent to the parties by facsimile or U.S. mail. The provider may appeal
an adverse decision on the request for reconsideration to the New Mexico Human
Services Department's Hearings Bureau pursuant to the 8.353.10 NMAC. The MAD
Director or designee shall make the decision on the recommendation from the
hearing officer.
B.
Specific Reconsideration Process for Nursing Facility, Intermediate Care
Facility for the Mentally Retarded Providers: The reconsideration
process for audit settlement varies for the aforementioned providers. See
8.312.3 NMAC, COST RELATED REIMBURSEMENT FOR NURSING FACILITIES, and 8.313.3
NMAC, COST RELATED REIMBURSEMENT OF ICF/MR FACILITIES for specific
information.
