Notice Of Internal Panel Review Decision

A. Notice requirements. The health care insurer shall notify the grievant and provider of the internal panel’s decision within 24 hours by telephone and in writing by mail or electronic communication sent within one day after the initial attempt to provide telephonic notice, unless earlier notice is required by the medical exigencies of the case. B. Contents of notice. If the initial decision denying certification is upheld in whole or in part, then the panel’s written notice shall contain: (1) the names, titles and qualifying credentials of the persons on the internal review panel; (2) a statement of the internal review panel’s understanding of the nature of the grievance and all pertinent facts; (3) a description of the evidence relied on by the internal review panel in reaching its decision; (4) if an adverse determination is upheld based on a determination that the requested service is experimental, investigational or not medically necessary, then: (a) clearly and completely explain why the requested health care service is not medically necessary, is experimental or investigational; a statement that the health care service is not medically necessary, is experimental or investigational will not be sufficient; and (b) include a citation to the uniform standards relevant to the grievant’s medical condition and an explanation of whether each supported or did not support the decision regarding a determination that the requested service is experimental, investigational, or medically necessary. (5) if an adverse determination is upheld based on a lack of coverage, identify all health benefits plan provisions relied on in making the adverse determination, and clearly and completely explain why the requested health care service is not covered by any provision of the health benefits plan; a statement that the requested health care service is not covered by the health benefits plan will not be sufficient; (6) if the service has already been provided, then include the date of service, the provider, the claim amount (if applicable), and a statement describing the availability, upon request, of the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning; (7) if the grievant is covered by the New Mexico Health Care Purchasing Act, then advise the grievant of the grievant’s right to request review from and in the manner designated by an entity authorized to purchase health care benefits pursuant to the New Mexico Health Care Purchasing Act and that the entity must review the grievant’s request before grievant can request an external review through OSI; (8) if the adverse determination involved medical judgment, including a determination based on medical necessity, appropriateness, health care setting, level of care, effectiveness or that the requested health care service is experimental or investigational, notice of the grievant’s right to request external review by an IRO within four months, including the address and telephone number of the MHCB, a description of all procedures necessary to pursue an IRO external review, copies of any forms required to initiate an IRO external review; or (9) if the adverse determination did not involve medical judgment, notice of the grievant’s right to request external review by the superintendent and copies of any forms required to initiate an external review by the superintendent. C. Information for requesting an external review. Notice of the grievant’s right to request an external review shall include the address and telephone number of the MHCB, a description of all procedures and time deadlines necessary to pursue an external review, copies of all forms required to initiate an external review and the following language: “We have denied your request for the provision of or payment for a health care service or course of treatment. You may have the right to have our decision reviewed, at no cost to you, by an impartial Independent Review Organization (IRO) who has no association with us and is appointed by the Office of Superintendent of Insurance (OSI). If our decision involved making a judgment as to the medical necessity, the experimental nature or the investigational nature of the requested service, or the appropriateness, health care setting, or level of care, then the Independent Review Organization (IRO) review will be performed by one or more health care professionals. You may also request an external review by OSI for rescission or adverse determinations that do not involve medical judgment. For more information contact OSI by electronic mail at mhcb.grievance@osi.nm.gov; by telephone at (505) 827-4601; or toll- free at 1- (855)-427-5674. You may also visit the OSI website at http://www.osi.state.nm.us for more information.” 13.10.17 NMAC 12 D. Grievance discontinued. If the grievant informs the health care insurer by telephone that the grievant does not wish to pursue the grievance, the health care insurer’s notice shall include written confirmation of the grievant’s decision not to pursue the matter further. E. Grievant’s decision unknown. If the health care insurer is unable to contact the grievant by telephone within one day of the panel’s decision to uphold the adverse determination, the health care insurer’s written notice shall include all information necessary to request an external review. [13.10.17.17 NMAC - Rp, 13.10.17.22 NMAC, 1/1/2017; A, 11/19/2024] 13.10.17.18 ADDITIONAL REVIEW BY ENTITIES SUBJECT TO THE NEW MEXICO HEALTH CARE PURCHASING ACT: A. Applicability. This section applies only to entities and grievants subject to the New Mexico Health Care Purchasing Act (public employees and retirees, public school employees and retirees only). B. Eligibility for review. A grievant who remains dissatisfied with the decision of the health care insurer after the completion of the internal panel review must have their claim reviewed in accordance with any review process established by the entity providing their health care benefits pursuant to the New Mexico Health Care Purchasing Act. C. Decision to uphold. If the health care insurer has upheld the initial adverse determination to deny the requested health care service at both the first level internal review and the internal panel review, the health care insurer shall notify the grievant that their grievance must be reviewed by their specific review board before their grievance may be eligible for an external review through OSI including an IRO review, as defined by their policy. The health care insurer shall ascertain whether the grievant wishes to pursue the grievance before the specific review board. (1) If the grievant does not wish to pursue the grievance, the health care insurer shall include confirmation of the grievant’s decision not to pursue the matter further with the written notification of the health care insurer’s decision as described in Subsection B of 13.10.17.17 NMAC. (2) If the health care insurer is unable to contact the grievant by telephone within one day of the panel’s decision to uphold the adverse determination, the health care insurer shall send a written inquiry, as described in Subsection D of 13.10.17.17 NMAC. (3) If the grievant responds affirmatively to the telephone or written inquiry the matter will proceed to a review by the grievant’s specific review board, according to the procedures contained in the grievant’s policy handbook. D. Extending the timeframe for review. If the grievant does not make an immediate decision to pursue the grievance, the grievant has requested additional time to supply supporting documents or information, or has asked for postponement, the timeframe shall be extended to include the additional time required by the grievant. E. Notice following review by the specific review board. (1) Certification. Upon receipt of notice from grievant’s specific review board that the requested benefit shall be certified, the health care insurer shall provide coverage in accordance to the review board’s decision. (2) Adverse determination upheld. Upon receipt of notice that grievant’s specific review board upholds the decision denying certification, then MHCB shall contact the grievant to determine whether grievant wishes to request an external review. If the MHCB is unable to contact the grievant by telephone within 24 hours, then MHCB will attempt to contact the grievant and the provider in writing by mail or electronically on the following day.