N.M. Admin. Code § 13.10.11.17

Current through Register Vol. 35, No. 23, December 10, 2024

Section 13.10.11.17 - COMPLAINT AND GRIEVANCE PROCEDURES

In the event an insured, an agent, a group or a member believes the performance of the alliance or a member does not meet its expectations or conform to a policy or plan issued by a member through the alliance, that person may bring the matter to the attention of the alliance by a complaint or grievance. The alliance shall act promptly and impartially when considering all complaints and grievances.

A. Definitions. As used in this section:

(1) complaint means a relatively minor verbal or written expression of concern which may lend itself to resolution on an informal basis and which relates to the operation or decision of the alliance or a member of the alliance;

(2) grievance means a more serious written expression of concern or a complaint which had not been resolved to the person's satisfaction; both situations require a thorough investigation and a formal response to the parties;

(3) group means a small employer group eligible for coverage or covered by an insurance policy, nonprofit health care plan contract or HMO plan issued through the alliance by a member; and

(4) insured means a person covered under an insurance policy or a nonprofit health care plan contract, or enrolled in an HMO plan issued through the alliance by a member;

B. Handling a complaint. Complaints should be made to the executive director of the alliance. The executive director has the discretionary power to handle complaints on an informal basis. The grievance procedure outlined in Subsection C of 13.10.11.17 NMAC will be followed if the complainant or the responding party wishes to appeal the decision of the executive director, if a determination has already been made by the executive director, or if the executive director decides that the issue at hand needs to be reviewed by the grievance committee of the alliance.

C. Grievance procedure.

(1) Between an insured or group and a member.

(a) If the grievance is between an insured or a group and a member, the insured or group shall complete all internal complaint and grievance procedures offered by a member prior to filing a grievance with the alliance.

(b) An insured or group must submit the grievance in writing to the alliance within 30 days following completion of the member's internal complaint or grievance process. If the member has no internal complaint or grievance process, or if the member has failed to respond to the complaint or grievance within 30 days after the insured or the group had made the complaint or grievance, the grievance must be submitted in writing to the alliance within 90 days after the incident occurred.

(c) The grievance should accurately describe the incident and must be signed by the insured or group filing the grievance.

(d) Upon receipt of the written grievance, the executive director of the alliance shall conduct a thorough review of the grievance and mail a response to the insured or group and to the member. If the parties are satisfied with the solution, the grievance matter shall be considered resolved.

(e) If the insured or group or the member is not satisfied with the solution proposed by the executive director, the grievance may be appealed in writing to the grievance committee of the alliance. Such appeal must be submitted within 30 days of the first grievance response and must include the reason for the appeal.

(2) Against the Alliance.

(a) Any person (including the insured, an agent, a group or a member) filing a grievance against the alliance must submit the grievance in writing to the alliance within 90 days after the incident occurred or within 90 days after the executive director makes an adverse decision on the complaint.

(b) The grievance should accurately describe the incident and must be signed by the person filing the grievance.

(c) Upon receipt of the written grievance, the executive director shall conduct a thorough review of the grievance and mail a response to the person. If the person is satisfied with the solution, the grievance matter shall be considered resolved.

(d) If the person is not satisfied with the solution proposed by the executive director, the grievance may be appealed in writing to the grievance committee of the alliance. Such appeal must be submitted within 30 days of the first grievance response and must include the reasons for the appeal.

D. Grievance committee.

(1) The grievance committee shall be composed of at least three members of the alliance's board of directors. Any director who represents a member or insured who is involved in a grievance shall not serve on the committee hearing the grievance.

(2) The committee shall convene 30 days after receipt of the appeal. The person filing the grievance will be invited to appear before the committee, along with any other parties involved in the grievance, to explain the appeal. After reviewing all previous findings of the plan and the executive director, and such other information as the committee may reasonably request, the committee will render a decision and deliver such in writing to all parties within 60 days after receipt of the appeal, unless good cause exists to extend the time. All decisions of the grievance committee are considered final.

(3) If any party involved is dissatisfied with the decision of the grievance committee, they may contact the New Mexico insurance division or they may pursue other remedies available to them. Prior to the filing of any legal proceedings or suit against the alliance or a member of the alliance, the complaint and grievance procedure prescribed in 13.10.11.17 NMAC must be utilized by any party alleging a claim.

(4) In adopting and utilizing this procedure to resolve disputes between a group or an insured and a member, the alliance and its grievance committee are providing a forum for alternative dispute resolution. Neither the alliance nor its grievance committee shall be a proper party to any dispute or suit between an insured or a group and a member.

N.M. Admin. Code § 13.10.11.17

13.10.11.17 NMAC - N, 6-1-01; A, 3-31-08