N.M. Admin. Code § 8.314.5.20

Current through Register Vol. 35, No. 20, October 22, 2024

Section 8.314.5.20 - RIGHT TO A HSD ADMINISTRATIVE HEARING

An eligible recipient may request a HSD administrative hearing to appeal a decision of MAD or its third party assessor contractor, that is an adverse action against the recipient. Prior to the fair hearing an eligible recipient may be offered an agency review conference. An agency review conference (AC) means an optional conference offered by HSD to provide an opportunity to informally resolve a dispute over the denial, suspension, reduction, termination or modification of DDW benefits or services. An AC will be attended by the recipient and their authorized representative if applicable, representatives of the TPA, HSD and any other necessary parties. The recipient may also bring whomever they wish to assist during the AC. The AC is optional and shall in no way delay or replace the fair hearing process or affect the deadline for a fair hearing request.

A. An authorized representative means any individual designated by the eligible recipient or their guardian, if applicable, to represent the recipient and act on their behalf. The authorized representative must provide formal documentation authorizing them to access the identified case information for this specific purpose. An authorized representative may be, but need not be, the recipient's guardian or attorney.

B. The HSD will issue written notification describing the outcome of the AC and any agreements within seven business days of the AC to the recipient, recipient's guardian if applicable, and case manager.

C. Unless the fair hearing request is withdrawn by the recipient or recipient's guardian or lawyer, any requested fair hearing will proceed. At the fair hearing the claimant may raise any relevant issue and present any relevant information that they choose. See 8.352.2 NMAC for a description of a claimant's HSD administrative hearing rights and responsibilities.

D. In addition to the requirements set forth in 8.352.2 NMAC, HSD shall take such actions as are necessary to assure the presence at the hearing of all necessary witnesses within DOH's control, including, when relevant to a denial of services or when requested by the claimant, a representative of the TPA with knowledge of the claimant's case and the reason(s) for the denial, in whole or in part, of any requested services.

E. Denials of services through the exception authorization process or other actions during this process adverse to the participant can also be appealed through a fair hearing.

F. All HSD administrative hearings are conducted in accordance with state and federal law.

G. No ex parte communications with an HSD administrative law judge are permitted by any DDW participant or counsel regarding any pending case. The MAD director shall not have ex parte communications regarding any pending cases with any DDW participant or counsel involved in that case. The MAD director's decision shall be limited to an on the record review.

N.M. Admin. Code § 8.314.5.20

8.314.5.20 NMAC - Rn, & A, 8.314.5.19 NMAC, 6-15-14, Amended by New Mexico Register, Volume XXVI, Issue 02, January 30, 2015, eff. 2/1/2015, Adopted by New Mexico Register, Volume XXVII, Issue 04, February 29, 2016, eff. 3/1/2016, Adopted by New Mexico Register, Volume XXIX, Issue 22, November 27, 2018, eff. 12/1/2018, Amended by New Mexico Register, Volume XXXIII, Issue 06, March 22, 2022, eff. 4/1/2022, Amended by New Mexico Register, Volume XXXV, Issue 05, March 12, 2024, eff. 4/1/2024