N.M. Admin. Code § 13.10.16.9

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

Section 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.

N.M. Admin. Code § 13.10.16.9

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