TITLE 13 INSURANCE
CHAPTER 10 HEALTH INSURANCE
PART 16 PROVIDER GRIEVANCES
13.10.16.1 ISSUING AGENCY: Office of
Superintendent of Insurance (“OSI”).
[13.10.16.1
NMAC - Rp, 13.10.16.1 NMAC, 01/01/2023]
13.10.16.2 SCOPE:
A. This rule applies
to every:
(1) health insurance carrier, as defined
in Paragraph (2) of Subsection C of Section 59A-16-21.2 NMSA 1978;
(2) vision
and dental plans that use a provider network; and
(3) multiple employer welfare arrangement
(individually a “carrier” and collectively “carriers”).
B. A carrier is not
subject to this rule with respect to any “health benefits plan” or “plan” as
defined in Paragraph (1) of Subsection C of Section 59A-16-21.2 NMSA 1978,
which only provides “excepted benefits,” as this term is defined in Subsection
B of Section 59A-23G-2 NMSA 1978.
[13.10.16.2
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13.10.16.3 STATUTORY AUTHORITY: Sections
59A-16-21.1, 59A-23-14, 59A-46-54, 59A-47-49 and 59A-57-6 NMSA 1978.
[13.10.16.3
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13.10.16.4 DURATION: Permanent.
[13.10.16.4
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13.10.16.5 EFFECTIVE DATE: January 1, 2023,
unless a later date is cited at the end of a section.
[13.10.16.5
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13.10.16.6 OBJECTIVE: The purpose of
this rule is to mandate provider grievance processes that are fair, efficient
and compliant with all applicable state and federal laws, and to specify
practices and procedures for external OSI review of provider grievance appeals.
[13.10.16.6
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13.10.16.7 DEFINITIONS:
A. Terms used in this rule are as defined in Section 59A-22B-2 NMSA
1978 and in 13.10.29 NMAC.
B. For the purposes of this rule, the
subsequent term is supplemented and superseded as follows; “Termination” means the discontinuance of a provider’s employment,
contractual relationship or other business relationship with, and initiated by,
a carrier.
[13.10.16.7
NMAC - Rp, 13.10.16.7 NMAC, 01/01/2023]
13.10.16.8 GENERAL RULES: A carrier shall
adopt and implement a provider grievance plan that complies with this rule.
This rule does not preclude a carrier and provider from addressing or resolving
a concern through any other process agreed on between them, but no such
alternative process shall preclude a provider from presenting a grievance
through a process that complies with this rule.
A. Allowed grievances. At a minimum, a carrier’s provider
grievance plan shall allow a provider to present any concern regarding:
(1) credentialing
deadlines;
(2) claim
payment amount or timing;
(3) claim
submission requirements or compliance;
(4) network
adequacy, including participation determinations based on network composition;
(5) network
composition including provider qualifications;
(6) utilization
management practices;
(7) provider
contract construction or compliance;
(8) patient
care standards or access to care;
(9) surprise
billing reimbursement amount, rate or timing;
(10) termination;
(11) operation
of the plan including compliance with any law enforceable by the
superintendent, or of any directive of the superintendent; or
(12) Discrimination.
B. Timeline to file. A
provider grievance plan shall allow a provider at least 90 days from the incident
that is the subject of the grievance, to file a grievance.
C. Filing procedures and response. A provider
grievance plan shall allow a provider to submit a written grievance electronically
or manually. A carrier shall send a written acknowledgment of the grievance to
the provider within five days of its receipt of the grievance using the
provider’s preferred communication method.
D. Point of contact. A
provider grievance plan may require the submission of a complaint to a
designated contact, as specified in the carrier’s provider manual which shall
identify the designated contact by name or position and provide a valid mailing
address, phone number, and email address for the designated point of contact.
E. Request for supplemental information. A provider
grievance plan may allow a carrier to request supplemental information
pertinent to the resolution of a grievance from the provider. Any such request
shall be made within 10 days of the carrier’s receipt of a grievance, and shall
require the provider to submit the requested supplemental information within
the next 10 days.
F. Review panel. A provider grievance plan
shall, at a minimum, require a carrier to form a review panel comprised of multiple
members, at least one of whom is in a position of authority over the carrier
operations that are the subject of a grievance. The review panel shall be
responsible for reviewing and deciding the provider’s grievance. If the
grievance raises a quality-of-care concern the panel must include a New Mexico-licensed
medical professional who practices in the general area of concern. A New Mexico-licensed
physician shall be included on a review panel considering complex
quality-of-care concerns. No person with a conflict of interest shall
participate in a decision to resolve a grievance. Employment with the carrier, standing
alone, does not present a conflict of interest.
G. Response. A provider grievance plan
shall require a carrier to deliver a written response, to a grievance using the
provider’s preferred method of communication within 45 days of the later of
receipt of the grievance, receipt of supplemental information requested to
resolve the grievance, or the due date for submission of any requested
supplemental information. The response shall include:
(1) the
name(s), title(s), and qualification(s) of each person who participated in the
grievance decision;
(2) a
statement of issue(s) decided and of the ultimate decision(s);
(3) a
clear and complete explanation of the rationale for the decision and a summary
of the evidence relied upon to support the decision;
(4) a
summary of any proposed remedial action; and
(5) information
on the provider’s appeal rights.
H. Extension of deadlines. If confirmed in
a documented communication a carrier and provider may agree to extend any
deadline imposed by this rule or a provider grievance plan.
I. Presentation of evidence. A provider
grievance plan shall include reasonable procedures by which a provider may
present oral or documentary evidence to the assigned grievance panel.
J. Bundled or group
grievances. A provider grievance plan shall allow a provider to submit
multiple related grievances simultaneously provided the grievances are not
unduly duplicative or repetitive, and for a group of providers to assert a
single grievance on behalf of multiple providers.
K. Non-participating providers.
A carrier’s provider grievance plan shall allow a non-participating provider to
submit a grievance described in Paragraphs (1), (2), (4), (5), (6), (9) or (12)
of Subsection A of this section. The grievance must assert and explain that the
carrier’s act or practice directly impacted the non-participating provider or a
patient of that provider.
[13.10.16.8
NMAC - Rp, 13.10.16.8 NMAC, 01/01/2023]
13.10.16.9 PROVIDER TERMINATION: For a grievance
that concerns a termination a provider grievance plan shall also comply with this
section.
A. Terminations for cause. If a termination
for cause, the provider grievance plan shall provide a fair hearing process
that provides these minimum rights and protections:
(1) the
right of the provider to appear in person at a hearing before the deciding panel;
(2) the
right of the provider to present testimonial or documentary evidence at the
hearing;
(3) the
right of the provider to call witnesses, and cross-examine any witness;
(4) the
right of the provider to be represented by an attorney or by any other person
of the provider’s choice;
(5) the
right to an expedited hearing within 14 days of the termination in those
instances where the carrier has not provided advance written notice of
termination and the termination could result in imminent and significant harm
to a covered person;
(6) a
written decision within 20 days after the hearing, contemporaneously delivered
via the provider’s preferred method of communication; and
(7) if
a group of providers is terminated for cause, each provider in the group shall
have an individual right to a hearing. However, if any one of the providers in
the group submits a grievance relating to the termination the carrier shall
provide each similarly situated provider in the group with a notice of hearing,
and each provider who receives such notice shall be bound by the carrier’s
determination subject to any appeal rights.
B. Other terminations. If a termination is not for
cause, the provider grievance plan shall require the carrier to furnish the
provider written notice at least 60 days before the effective date of
termination. Such notice shall:
(1) be
communicated in writing via the format preferred by the provider; and
(2) contain
an explanation of the termination.
[13.10.16.9
NMAC - Rp, 13.10.16.9 NMAC, 01/01/2023]
13.10.16.10 APPEALS:
At the request of a provider, the superintendent shall conduct an external
review of a provider grievance as authorized by this section.
A. Types
of grievances subject to appeal. The superintendent shall only review a
provider grievance that pertains to:
(1) an
alleged violation of a law enforceable by the superintendent;
(2) alleged
noncompliance with an order of the superintendent; or
(3) a
termination based on a provider’s alleged failure to comply with a law or order
enforceable by the superintendent.
B. Disposition. In the disposition of an appeal, the
superintendent may only impose a remedy, penalty, or corrective action
authorized by the Insurance Code.
C. Exhaustion of internal remedies required. The
superintendent shall not review a provider grievance appeal unless the provider
has exhausted the carrier’s internal grievance process.
D. Timeline for filing
appeal. A provider appeal of a grievance shall be filed no later than 30
days after the provider receives a response to the grievance, or the deadline
for the response, whichever is earlier.
E. Appeal content. The superintendent
shall not review a provider grievance appeal that does not contain the
following information:
(1) the
provider’s name, license number, address, daytime telephone number, email
address, and any relevant claim number(s);
(2) the
name and phone number of the carrier;
(3) certification
that the grievance did not pertain to Medicaid or Medicare coverage, excluding Medicare
supplement;
(4) a
copy of the carrier’s written disposition of the grievance, or certification by
the provider that the carrier did not issue a written disposition within the
time allowed by law;
(5) the
date the provider received the carrier’s written disposition of the grievance,
or the date by which the carrier was required to provide a written disposition
if no disposition was received; and
(6) a
clear and concise statement of the issue on appeal, and the remedy requested on
appeal. F. Additional documentation. Within 45
days of receipt of a provider grievance appeal, the superintendent shall
determine whether the appeal is authorized by this section and otherwise
reviewable. The superintendent may request supplemental information from the
provider or carrier to so determine. The time between any such request and the delivery
of the requested information by the superintendent shall be excluded from the
45-day deadline imposed by this section.
(1) If
the superintendent determines that an appeal is not authorized or reviewable,
the superintendent shall issue an order
dismissing the
appeal and stating the reason for dismissal.
(2) If
the superintendent determines that an appeal is authorized and reviewable, the
superintendent shall schedule either a formal or an informal hearing pursuant
to the superintendent’s rules, as appropriate to the issues, facts and
circumstances presented in the appeal. The order setting the hearing shall
authorize a designated hearing officer to take or authorize any action
authorized by law to resolve the appeal.
G. Settlement. The
superintendent may order the parties to an appeal to participate in formal or
informal settlement discussions focused on resolving the issue on appeal. If
all parties to an appeal consent, the assigned hearing officer may facilitate
the settlement discussions without being disqualified from issuing a recommended
decision on appeal.
H. Waiver. Upon an express finding of good
cause, the superintendent may waive any deadline, format or process requirement
imposed by this section.
[13.10.16.10
NMAC - Rp, 13.10.16.10 NMAC, 01/01/2023]
13.10.16.11 RETALIATORY
ACTION PROHIBITED: No person shall be subject to retaliatory action by a
carrier for submitting or supporting a grievance or appeal.
[13.10.16.11
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13.10.16.12 PROVIDER
MANUAL: A carrier’s provider manual shall include a clear statement of a
provider’s right to grieve, the internal grievance process, the right of appeal
and the appeal process. The carrier shall publish its provider grievance plan
on a website accessible to any provider.
[13.10.16.12
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13.10.16.13 REPORTING AND COMPLIANCE:
A. Provider grievance
plan publication and changes. No carrier shall publish a provider grievance
plan., or any amendment of a provider grievance plan., that has not been
reviewed and approved by the superintendent. A provider grievance plan shall be
deemed approved if the superintendent fails to expressly approve, disapprove,
or object to the provider grievance plan within 60 days from submission.
B. Submission of provider
grievance plan. In conjunction with the provider contract certificate, a
carrier shall submit a provider grievance plan for the superintendent’s review
and approval. At a minimum, the provider grievance plan shall include:
(1) a
description of the procedures used by the carrier to receive, review, and
respond to a provider grievance;
(2) the
criteria and process the carrier uses to select the persons responsible for
reviewing and responding to a provider grievance;
(3) the
procedures by which the carrier’s governing body is informed of provider
grievances and the carrier’s responses; and
(4) the
title of staff responsible for implementation and oversight of the provider
grievance process.
C. Grievance log. A carrier shall maintain
a detailed log of provider grievances and their resolutions for a period of no
less than five years. The carrier shall make the log available to the
superintendent upon request.
[13.10.16.13
NMAC - N, 01/01/2023]
13.10.16.14 SEVERABILITY: If any section
of this rule, or the applicability of any section to any person or
circumstance, is for any reason held invalid by a court of competent jurisdiction,
the remainder of the rule, or the applicability of such provisions to other
persons or circumstances, shall not be affected.
[13.10.16.14
NMAC – N, 01/01/2023]
History of 13.10.16
NMAC:
13.10.16 NMAC – Provider Grievances, filed
12/01/1998, Recompiled 11/30/2001, was repealed and replaced by 13.10.16 NMAC –
Provider Grievances, effective 01/01/2023.