N.M. Admin. Code § 13.10.16.10

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

Section 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.

N.M. Admin. Code § 13.10.16.10

12/1/98; Recompiled 11/30/01, Adopted by New Mexico Register, Volume XXXIII, Issue 18, September 27, 2022, eff. 1/1/2023