Internal panel review of adverse determinations
A. Applicability of internal panel review.
(1) A health care insurer that offers managed health care plans shall establish a panel review process for its managed health care plans to give those grievants who are dissatisfied with the internal review decision the option to request a panel review, at which the grievant has the right to appear in person before a panel of designated representatives of the health care insurer.
(2) This section also applies to persons covered under the New Mexico Health Care Purchasing Act (public employees and retirees, public school employees and retirees only).
B. Acknowledgment of request. Upon receipt of a request for internal panel review of an adverse determination, the health care insurer shall date and time stamp the request and:
(1) for a standard internal panel review, within three working days after receipt of the request, send the grievant an acknowledgment that the request has been received; or
(2) for an expedited internal panel review, acknowledge the request telephonically or by electronic communication; and
(3) the acknowledgment shall:
(a) contain the name, address and direct telephone number of an individual representative of the health care insurer who may be contacted regarding the grievance;
(b) specify the date, time and location for the internal panel review meeting and provide a toll-free number for the grievant to participate telephonically;
(c) include the grievant’s rights as set forth below; and
(d) inform the grievant if the health care insurer will be represented by an attorney.
C. Grievant’s rights. The health care insurer shall notify the grievant of the grievant’s right to:
(1) request the opportunity to appear in person or telephonically before an internal review panel comprised of the health care insurer’s designated representatives;
(2) present the grievant’s case to the internal review panel orally or in writing;
(3) submit written comments, documents, records, and other material relating to the request for benefits for the internal review panel to consider when conducting the review both before and, if applicable, at the review panel’s meeting;
(4) if applicable, ask questions of any representative of the health care insurer or health care professional on the internal review panel;
(5) be assisted or represented by an individual of the grievant’s choice, including legal representation at the grievant’s expense;
(6) hire a specialist to participate in the internal panel review at the grievant’s expense, but such specialist may not participate in making the decision; and
(7) request a postponement of the internal panel review for up to 30 days.
D. Conduct of the internal panel review.
(1) Upon receipt of a grievant’s request for an internal panel review, the health care insurer shall appoint a panel to review the request.
(a) The health care insurer shall select representatives of the health care insurer and if the adverse determination was based on a determination that the requested service is not a medical necessity, is experimental or investigational, or is considered not a covered benefit, one or more qualified health care professionals shall serve on the internal review panel. At least one of the health care professionals selected shall be a clinical peer that practices in a specialty that would typically manage the case that is the subject of the grievance or be mutually agreed upon by the grievant and the health care insurer.
(b) A panel shall be comprised of individuals who have no financial interest in the outcome of the review and who were not involved in the initial determination or the first internal review decision, except that an individual who was involved in the first internal review decision may appear before the panel to present information or answer questions.
(2) In conducting the review, the internal review panel shall take into consideration all comments, documents, records and other information regarding the request for benefits submitted by the grievant, without regard to whether the information was submitted or considered in reaching the initial determination or the first internal review decision.
(3) The internal review panel shall have the legal authority to bind the health care insurer to the panel’s decision.
(4) If the initial adverse determination was based on a lack of coverage, the internal review panel shall review the health benefits plan and determine whether there is any provision in the plan under which the requested health care service could be certified. If the internal review panel finds that the requested health care benefit is not covered by the health benefits plan, the panel shall issue its final adverse determination in accordance with this rule.
(5) If the initial adverse determination was based on a determination that the requested service is experimental, investigational or not a medical necessity, the internal review panel shall render an opinion, either after consultation with specialists who are experts in the area that is the subject of review, or after application of uniform standards used by the health care insurer.
(6) Internal review panel members must be physically present or attend the panel by video or telephone conferencing to participate in the decision.
E. Information to grievant. No fewer than three days prior to the internal panel review, the health care insurer shall provide to the grievant copies of all documents that will be considered in reviewing the grievant’s request for benefits, including, if applicable:
(1) the grievant’s pertinent medical records;
(2) the treating provider’s recommendation;
(3) relevant sections of the grievant’s health benefits plan;
(4) the health care insurer’s notice of adverse determination;
(5) uniform standards relevant to the grievant’s medical condition that shall be used by the internal panel in reviewing the adverse determination;
(6) questions sent to or reports received from any medical consultants retained by the health care insurer; and
(7) all other evidence or documentation relevant to reviewing the adverse determination.
F. Request for postponement. The health care insurer shall not unreasonably deny a request for postponement of the internal panel review for up to 30 days made by the grievant. The timeframes for completing the internal panel review shall be extended during the period of any postponement.
G. Additional requirements for expedited internal panel review of an adverse determination.
(1) In an expedited review, all information required to be exchanged by Section E. of 126.96.36.199 NMAC shall be transmitted between the health care insurer and the grievant by the most expedient method available.
(2) If an expedited review is conducted during a grievant’s hospital stay or approved on-going course of treatment, health care services shall be continued without cost (except for applicable co-payments, co-insurance and deductibles) to the grievant until the health care insurer makes a final decision and notifies the grievant.
(3) A health care insurer shall not conduct an expedited internal panel review of post-service claims.