TITLE 8 SOCIAL
SERVICES
CHAPTER 349 COORDINATED SERVICE CONTRACTORS
PART 2 APPEALS AND GRIEVANCE PROCESS
8.349.2.1 ISSUING AGENCY: New Mexico
Human Services Department.
[8.349.2.1 NMAC - N, 3-1-06]
8.349.2.2 SCOPE: The rule applies
to the general public.
[8.349.2.2 NMAC - N, 3-1-06]
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 human services department pursuant to
state statute. See NMSA 1978, section
27-2-12 et seq. (Repl. Pamp. 1991).
[8.349.2.3 NMAC - N, 3-1-06]
8.349.2.4 DURATION: Permanent
[8.349.2.4 NMAC - N, 3-1-06]
8.349.2.5 EFFECTIVE DATE: March 1, 2006,
unless a later date is cited at the end of a section.
[8.349.2.5 NMAC - N, 3-1-06]
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 - N, 3-1-06]
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 - N, 3-1-06]
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 HSD 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 and/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 HSD 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 - N, 3-1-06]
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 human services department
(HSD). 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 and/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 authority to administer the policies
and procedures for resolution of a grievance and/or an appeal, to review
patterns/trends in grievances and/or appeals, and to initiate corrective
action.
E. The
CSC shall ensure that the individuals that make the decisions on grievances
and/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 and/or their representative(s)
can file a grievance and/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 HSD 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 and/or an appeal, or a provider
that supports a recipients's grievance and/or appeal.
[8.349.2.10 NMAC - N, 3-1-06]
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
ninety (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 (5) 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 thirty (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 HSD up to fourteen (14) calendar days if the
grievant requests the extension, or the CSC demonstrates to HSD 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 (2) 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/or 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 - N, 3-1-06]
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 HSD; 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/or provider with in 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 HSD
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 ninety (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 thirty (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 (5) 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 thirty (30) days time frame by fourteen (14) calendar days
if the recipient requests the extension, or the CSC demonstrates to HSD 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 (2) working days
of the decision to extend the time frame.
H. The
CSC shall provide the recipient and/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 and/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 his or her representative, or the legal representative of a
deceased recipient's estate.
J. For
all appeals, the CSC shall provide written notice within the thirty
(30)-calendar-day timeframe for resolution to the grievant, legal guardian,
representative, and/or 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 HSD 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 and/or the HSD 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 ten (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) ten (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) HSD 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 HSD 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 HSD 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 - N, 3-1-06]
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 (3) 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 fourteen (14) calendar days if the recipient
requests the extension, or the CSC demonstrates to HSD 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 thirty (30)-day
timeframe for standard resolution, in which the thirty (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 (2) calendar days; and
(3)
inform the grievant in the written notice of the right to file an appeal
and/or request an HSD 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 - N, 3-1-06]
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
seventy-two (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 - N, 3-1-06]
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
and/or appeal files:
(1) All grievance and/or appeal files shall be
maintained in a secure and designated area and accessible to HSD, upon request,
for review. Grievance and/or appeal
files shall be retained for six (6) years following the final decision by the
CSC, HSD, 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 and/or
appeal, the date it was received, the nature of the grievance and/or appeal,
notice to the recipient of receipt of the grievance and/or appeal, all
correspondence between the CSC and the recipient, the date the grievance and/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, and/or
provider acting on behalf of the recipient if requested.
[8.349.2.15 NMAC - N, 3-1-06]
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 and/or
provider payment issues. Grievances
shall be resolved within thirty (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 - N, 3-1-06]
History of 8.349.2 NMAC: [RESERVED]