TITLE 8 SOCIAL SERVICES
CHAPTER 349 COORDINATED SERVICE CONTRACTORS
PART 2 APPEALS
AND GRIEVANCE PROCESS
8.349.2.1 ISSUING AGENCY: New Mexico Health
Care Authority.
[8.349.2.1 NMAC - Rp
8.349.2.1 NMAC, 7/1/2024]
8.349.2.2 SCOPE: The rule
applies to the general public.
[8.349.2.2 NMAC - Rp 8.349.2.2
NMAC, 7/1/2024]
8.349.2.3 STATUTORY AUTHORITY: The New Mexico
medicaid program is administered pursuant to
regulations promulgated by the federal department of health and human services
under Title XIX of the Social Security Act, as amended, and by the state health
care authority pursuant to state statute.
See Section 27-2-12 et seq. NMSA
1978 (Repl. Pamp. 1991). Section 9-8-1 et seq.
NMSA 1978 establishes the health care
authority (HCA) as a single, unified department to administer laws and exercise
functions relating to health care facility licensure and health care purchasing
and regulation.
[8.349.2.3 NMAC - Rp 8.349.2.3 NMAC, 7/1/2024]
8.349.2.4 DURATION: Permanent.
[8.349.2.4 NMAC - Rp 8.349.2.4
NMAC, 7/1/2024]
8.349.2.5 EFFECTIVE DATE: July 1, 2024,
unless a later date is cited at the end of a section.
[8.349.2.5 NMAC - Rp 8.349.2.5
NMAC, 7/1/2024]
8.349.2.6 OBJECTIVE: The objective
of these regulations is to provide policies for the service portion of the New
Mexico medicaid program. These policies describe eligible providers,
covered services, noncovered services, utilization review, and provider
reimbursement.
[8.349.2.6 NMAC - Rp 8.349.2.6
NMAC, 7/1/2024]
8.349.2.7 DEFINITIONS: [RESERVED]
8.349.2.8 MISSION STATEMENT: The mission of
the New Mexico medical assistance division (MAD) is to maximize the health
status of medicaid-eligible individuals by furnishing
payment for quality health services at levels comparable to private health
plans.
[8.349.2.8 NMAC - Rp 8.349.2.8
NMAC, 7/1/2024]
8.349.2.9 COORDINATED SERVICE CONTRACTORS
(CSC): CSCs that manage some services of the medicaid program are responsible for any or all aspects of
program management, prior authorization, utilization review, claims processing,
and issuance of remittance advices and payments.
A. The
CSC shall have a grievance system in place for recipients that include a
grievance process related to dissatisfaction and an appeals process related to
a CSC’s action, including the opportunity to request an HCA fair hearing.
B. A
grievance is a recipient’s expression of dissatisfaction about any matter or
aspect of the CSC or its operation, other than a CSC’s action, as defined
below.
C. An
appeal is a request for review by the CSC of a CSC's action. An action is the denial or limited
authorization of a requested service, including the type or level of service;
the reduction, suspension, or termination of a previously authorized service;
the denial, in whole or in part, of payment for a service; or the failure to
provide services in a timely manner. An
untimely service authorization constitutes a denial and is thus considered an
action.
D. The
recipient, legal guardian of the recipient for a minor or an incapacitated
adult, or a representative of the recipient as designated in writing to the
CSC, has the right to file a grievance or an appeal of the CSC’s action on
behalf of the recipient. A provider
acting on behalf of the recipient, with the recipient’s written consent, may
file a grievance or an appeal of a CSC’s action.
E. In
addition to the CSC’s grievance and appeal process described above, a
recipient, legal guardian of the recipient for a minor or an incapacitated
adult, or the representative of the recipient has the right to request a fair
hearing on behalf of the recipient with HCA directly as described in 8.352.2
NMAC, Recipient Hearings, if a CSC’s decision results in termination,
modification, suspension, reduction, or denial of services to the recipient or
if the recipient believes the CSC has taken an action erroneously. A fair hearing may be requested prior to,
concurrent with, subsequent to, or in lieu of a
grievance or appeal to the CSC.
[8.349.2.9 NMAC - Rp 8.349.2.9
NMAC, 7/1/2024]
8.349.2.10 GENERAL REQUIREMENTS FOR GRIEVANCE
AND APPEALS:
A. The
CSC shall implement written policies and procedures describing how the
recipient may submit a request for a grievance or an appeal with the CSC or
submit a request for a fair hearing with the HCA. The policy shall include a description of how
the CSC resolves the grievance or appeal.
B. The
CSC shall provide to all service providers and subcontractors in the CSC's
network a written description of the CSC's grievance and appeal process and how
the provider can submit a grievance or appeal.
C. The
CSC shall have available reasonable assistance in completing forms and taking
other procedural steps. This includes,
but is not limited to, providing interpreter services and toll-free numbers
that have adequate TTY/TTD and interpreter capability.
D. The
CSC shall name a specific individual(s) designated as the CSC's medicaid recipient grievance coordinator with the HCA to
administer the policies and procedures for resolution of a grievance or an
appeal, to review patterns/trends in grievances or appeals, and to initiate
corrective action.
E. The
CSC shall ensure that the individuals that make the decisions on grievances or
appeals are not involved in any previous level of review or
decision-making. The CSC shall also
ensure that health care professionals with appropriate clinical expertise shall
make decisions for the following:
(1) an appeal of a CSC denial that is based on lack of medical
necessity;
(2) a CSC denial that is upheld in an expedited resolution;
(3) a grievance or appeal that involves clinical issues.
F. Upon
enrollment, the CSC shall provide recipients, at no cost, with an information
sheet or handbook that provides information on how they or their
representative(s) can file a grievance or an appeal, and the resolution
process. The recipient information shall
also advise recipients of their right to file a request for an administrative
hearing with the HCA hearings bureau, upon notification of a CSC action, or
concurrent with or following an appeal of the CSC action.
G. The
CSC shall ensure that punitive or retaliatory action is not taken against a
recipient or a provider that files a grievance or an appeal, or a provider that
supports a recipients’ grievance or appeal.
[8.349.2.10 NMAC - Rp
8.349.2.10 NMAC, 7/1/2024]
8.349.2.11 GRIEVANCE: A grievance is
a recipient's expression of dissatisfaction about any matter or aspect of the
CSC or its operation.
A. A
recipient may file a grievance either orally or in writing with the CSC within
90 calendar days of the date the event causing the dissatisfaction
occurred. The legal guardian of the
recipient for a minor or an incapacitated adult, a representative of the
recipient as designated in writing to the CSC, and a provider acting on behalf
of the recipient and with the recipient's written consent, have the right to
file a grievance on behalf of the recipient.
B. Within
five working days of receipt of the grievance, the CSC shall provide the
grievant with written notice that the grievance has been received and the
expected date of its resolution.
C. The
investigation and final CSC resolution process for grievances shall be
completed within 30 calendar days of the date the grievance is received by the
CSC and shall include a resolution letter to the grievant or the grievant’ s
representative.
D. The
CSC may request an extension from HCA up to 14 calendar days if the grievant
requests the extension, or the CSC demonstrates to HCA that there is need for
additional information, and the extension is in the recipient's interest. For any extension not requested by the grievant, the CSC shall give the grievant written notice of
the reason for the extension within two working days of the decision to extend
the timeframe.
E. Upon
resolution of the grievance, the CSC shall mail a resolution letter to the
grievant, legal guardian, representative, and provider acting on behalf of the
recipient. The resolution letter shall
include, but not be limited to, the following:
(1) all information considered in investigating the grievance;
(2) findings and conclusions based on the investigation; and
(3) the disposition of the grievance.
[8.349.2.11 NMAC - Rp
8.349.2.11 NMAC, 7/1/2024]
8.349.2.12 APPEALS: An appeal is a
request for review by the CSC of a CSC action.
A. An
action is defined as:
(1) the denial or limited authorization of a requested service,
including the type of level of service;
(2) the reduction, suspension, or termination of a previously
authorized service;
(3) the denial, in whole or in part, of payment for a service;
(4) the failure of the CSC to provide services in a timely
manner, as defined by HCA; or
(5) the failure of the CSC to complete the authorization
request in a timely manner as defined in 42 CFR 438.408.
B. The
CSC shall mail a notice of action to the recipient and provider within 10 days
of the date of the action, except for denial of claims that may result in
recipient financial liability, which requires immediate notification. The notice shall contain, but not be limited,
to the following:
(1) the action CSC has taken or intends to take;
(2) the reasons for the action;
(3) the recipient's or the provider's right to file an appeal
of the CSC action through the CSC;
(4) the recipient's right to request an HCA fair hearing and
what the process would be;
(5) the procedures for exercising the rights specified;
(6) the circumstances under which expedited resolution of an
appeal is available and how to request it; and
(7) the recipient's right to have benefits continue pending
resolution of an appeal, how to request the continuation of benefits, and the
circumstances under which the recipient may be required to pay the costs of
continuing these benefits.
C. A
recipient may file an appeal of a CSC action within 90-calendar days of
receiving the CSC's notice of action.
The legal guardian of the recipient for a minor or an incapacitated
adult, a representative of the recipient as designated in writing to the CSC,
or a provider acting on behalf of the recipient with the recipient's written
consent, have the right to file an appeal of an action on behalf of the
recipient.
D. The
CSC has 30-calendar days from the date the initial oral or written appeal is
received by the CSC to resolve the appeal.
E. The
CSC shall have a process in place that ensures that an oral or written inquiry
from a recipient seeking to appeal an action is treated as an appeal (to
establish the earliest possible filing date for the appeal). The CSC shall use its best efforts to assist
recipients as needed with the written appeal.
F. Within
five working days of receipt of the appeal, the CSC shall provide the grievant
with written notice that the appeal has been received and the expected date of
its resolution. The CSC shall confirm in
writing receipt of oral appeals, unless the recipient or the provider requests
an expedited resolution.
G. The
CSC may extend the 30 days time frame by 14 calendar
days if the recipient requests the extension, or the CSC demonstrates to HCA
that there is need for additional information, and the extension is in the
recipient's interest. For any extension
not requested by the recipient, the CSC shall give the recipient written notice
of the extension and the reason for the extension within two working days of
the decision to extend the time frame.
H. The
CSC shall provide the recipient or the recipient's representative
a reasonable opportunity to present evidence of the facts or law, in person as
well as in writing.
I. The
CSC shall provide the recipient or the representative the opportunity, before
and during the appeals process, to examine recipient's case file, including
medical or clinical records (subject to HIPAA requirements), and any other
documents and records considered during the appeals process. The CSC shall include as parties to the
appeal the recipient and their representative, or the legal representative of a
deceased recipient's estate.
J. For
all appeals, the CSC shall provide written notice within the 30-calendar-day
timeframe for resolution to the grievant, legal guardian, representative, and
provider acting on behalf of the recipient.
(1) The written notice of the appeal resolution shall include,
but not be limited to, the following information:
(a) the results of the appeal resolution;
and
(b) the date it was completed.
(2) The written notice of the appeal resolution for appeals not
resolved wholly in favor of the recipient shall include, but not be limited to,
the following information:
(a) the right to request an HCA fair
hearing and how to do so:
(b) the right to request receipt of
benefits while the hearing is pending, and how to make the request; and
(c) that the recipient may be held liable
for the cost of continuing benefits if the hearing decision upholds the CSC's
action.
K. The
CSC may continue benefits while the appeal or the HCA
fair hearing process is pending.
(1) The CSC shall continue the recipient's benefits if all of the following are met:
(a) the recipient or the provider files a
timely appeal of the CSC action within 10 days of the date on the notice of
action from the CSC);
(b) the appeal involves the termination,
suspension, or reduction of a previously authorized course of treatment:
(c) the services are ordered by an
authorized provider;
(d) the recipient requests extension of
benefits.
(2) The CSC shall provide benefits until one of the following
occurs:
(a) the recipient withdraws the appeal;
(b) 10 days have passed since the date of
the resolution letter, provided the resolution of the appeal was against the
recipient and the recipient has taken no further action;
(c) HCA issues a hearing decision adverse
to the recipient;
(d) the time period
or service limits of a previously authorized service has expired.
(3) If the final resolution of the appeal is adverse
to the recipient, that is, the CSC's action is upheld, the CSC may recover the
cost of the services furnished to the member while the appeal was pending, to
the extent that services were furnished solely because of the requirements of
this section and in accordance with the policy in 42 CFR 431.230(b).
(4) If the CSC or HCA reverses a decision to deny, limit, or
delay services, and these services were not furnished while the appeal was
pending the CSC shall authorize or provide the disputed services promptly and
as expeditiously as the recipient's health condition requires.
(5) If the CSC or HCA reverses a decision to deny, limit or
delay services and the recipient received the disputed services while the
appeal was pending, the CSC shall pay for these services.
[8.349.2.12 NMAC - Rp
8.349.2.12 NMAC, 7/1/2024]
8.349.2.13 EXPEDITED RESOLUTION OF APPEALS: An expedited
resolution of an appeal is an expedited review by the CSC of a CSC action.
A. The
CSC shall establish and maintain an expedited review process for appeals when
the CSC determines that allowing the time for a standard resolution could
seriously jeopardize the recipient's life or health or ability to attain,
maintain, or regain maximum function.
Such a determination is based on:
(1) a request from the recipient;
(2) a provider's support of the recipient's request;
(3) a provider's request on behalf of the recipient; or
(4) the CSC's independent determination.
B. The
CSC shall ensure that the expedited review process is convenient and efficient
for the recipient.
C. The
CSC shall resolve the appeal within three working days of receipt of the
request for an expedited appeal, if the request meets the definition of
expedited in 8.349.2.13 NMAC.
D. The
CSC may extend the time frame by up to 14 calendar days if the recipient
requests the extension, or the CSC demonstrates to HCA that there is need for
additional information and the extension is in the recipient's interest. For an extension not requested by the
recipient, the CSC shall give the recipient written notice of the reason for
the delay.
E. The
CSC shall ensure that punitive action is not taken against a recipient or a
provider who requests an expedited resolution or supports a recipient's
expedited appeal.
F. The
CSC shall provide an expedited resolution, if the request meets the definition
of an expedited appeal, in response to an oral or written request from the
recipient or provider on behalf of the recipient.
G. The
CSC shall inform the recipient of the limited time available to present
evidence and allegations in fact or law.
H. If
the CSC denies a request for an expedited resolution of an appeal, it shall:
(1) transfer the appeal to the 30-day timeframe for standard
resolution, in which the 30-day period begins on the date the CSC received the
original request for appeal;
(2) make reasonable efforts to give the recipient prompt oral
notice of the denial, and follow up with a written notice within two calendar
days; and
(3) inform the grievant in the written notice of the right to
file an appeal or request an HCA fair hearing if the recipient is dissatisfied
with the CSC's decision to deny an expedited resolution.
I. The
CSC shall document in writing all oral requests for expedited resolution and
shall maintain the documentation in the case file.
[8.349.2.13 NMAC - Rp
8.349.2.13 NMAC, 7/1/2024]
8.349.2.14 SPECIAL RULE FOR CERTAIN EXPEDITED
SERVICE AUTHORIZATION DECISIONS: In the case of expedited service
authorization decisions that deny or limit services, the CSC shall, within 72
hours of receipt of the request for service, automatically file an appeal on
behalf of the recipient, use its best effort, to give the recipient oral notice
of the decision on the automatic appeal and to resolve the appeal.
[8.349.2.14 NMAC - Rp
8.349.2.14 NMAC, 7/1/2024]
8.349.2.15 OTHER RELATED COORDINATED SERVICE
CONTRACTOR (CSC) PROCESSES:
A. Information
about grievance system to providers and subcontractors: The CSC shall provide information specified
in 42 CFR438.10(g) (1) about the grievance system to all providers and
subcontractors at the time that they enter into a
contract.
B. Grievance
or appeal files:
(1) All grievance or appeal files shall be maintained in a
secure and designated area and accessible to HCA, upon request, for
review. Grievance or appeal files shall
be retained for six years following the final decision by the CSC, HCA, and
administrative law judge, judicial appeal, or closure of a file, whichever
occurs later.
(2) The CSC shall have procedures for assuring that files
contain sufficient information to identify the grievance or appeal, the date it
was received, the nature of the grievance or appeal, notice to the recipient of
receipt of the grievance or appeal, all correspondence between the CSC and the
recipient, the date the grievance or appeal is resolved, the resolution, the
notices of final decision to the recipient, and all other pertinent
information.
(3) Documentation regarding the grievance shall be made
available to the grievant, legal guardian representative, or provider acting on
behalf of the recipient if requested.
[8.349.2.15 NMAC - Rp
8.349.2.15 NMAC, 7/1/2024]
8.349.2.16 COORDINATED SERVICE CONTRACTOR (CSC)
PROVIDER GRIEVANCE PROCESS: The CSC shall establish and maintain written
policies and procedures for the filing of provider grievances. A provider shall have the right to file a
grievance with the CSC regarding utilization management decisions or provider
payment issues. Grievances shall be
resolved within 30 calendar days. A
provider may not file a grievance on behalf of a recipient without written
designation by the recipient as the recipient's representative. See 8.349.2.14 NMAC for special rules for
certain expedited service authorizations.
[8.349.2.16 NMAC - Rp
8.349.2.16 NMAC, 7/1/2024]
History of 8.349.2 NMAC: [RESERVED]
History of Repealed
Material: 8.349.2 NMAC,Appeals And
Grievance Process, filed 12/13/2006 - Repealed effective 7/1/2024.
Other: 8.349.2
NMAC, Appeals And Grievance Process, filed 12/13/2006 Replaced by 8.349.2 NMAC,
Appeals And Grievance Process, effective 7/1/2024.