See bold text below:
As used in this rule:
A. “Administrative decision” means a decision made by a health care insurer regarding any aspect of a health benefits plan other than an adverse determination, including but not limited to:
(1) administrative practices of the health care insurer that affect the availability, delivery, or quality of health care services;
(2) claims payment, handling or reimbursement for health care services, including but not limited to complaints concerning co-payments, co-insurance and deductibles; and
(3) terminations of coverage.
B. “Administrative grievance” means an oral or written complaint submitted by or on behalf of a covered person regarding an administrative decision.
C. “Adverse determination” means any of the following:
(1) any rescission of coverage (whether or not the rescission has an adverse effect on any particular benefit at the time);
(2) a denial, reduction, or termination of, or a failure to make full or partial payment for a benefit including any such denial, reduction, termination, or failure to make payments, that is based on a determination of a covered person’s eligibility to participate in a health benefits plan; or
(3) a denial, reduction or termination of, or a failure to make full or partial payment for a benefit resulting from the application of any utilization review; or
(4) failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental, or investigational or not medically necessary or appropriate.
D. “Adverse determination grievance” means an oral or written complaint submitted by or on behalf of a covered person regarding an adverse determination.
E. “Certification” means a determination by a health care insurer that a health care service requested by a provider or covered person has been reviewed and, based upon the information available, meets the health care insurer’s requirements for determining medical necessity, appropriateness, health care setting, level of care and effectiveness, and the requested health care service is therefore approved.
F. “Clinical peer” means a physician or other health care professional who holds a non-restricted license in a state in the United States and in the same or similar specialty as typically manages the medical condition, procedure or treatment under review.
G. “Co-insurance” is a cost-sharing plan that requires an insured person to pay a stated percentage of medical expenses after the deductible amount, if any, was paid; co-insurance rates may differ for different types of services.
H. “Co-payment” is a cost-sharing plan that requires an insured person to pay a fixed dollar amount when a medical service is received or when purchasing medicine after the deductible amount, with the health care insurer paying the balance; there may be different co-payments for different types of service.
I. “Covered benefits” means those health care services to which a covered person is entitled under the terms of a health benefits plan.
J. “Covered person” means a policyholder, subscriber, enrollee or other individual participating in a health benefit plan.
K. “Culturally and linguistically appropriate manner of notice” means:
(1) Notice that meets the following requirements:
(a) the health care insurer must provide oral language services (such as the telephone customer assistance hotline) that includes answering questions in any applicable non-English language and providing assistance with filing claims and reviews (including IRO reviews and external reviews) in any applicable non-English language;
(b) the health care insurer must provide, upon request, a notice in any applicable non-English language; and
(c) the health care insurer must include in the English versions of all notices, a statement prominently displayed in any applicable non-English language clearly indicating how to access the language services provided by the health care insurer.
(2) For purposes of this definition, with respect to an address in any New Mexico county to which a notice is sent, a non-English language is an applicable non-English language if 10 percent or more of the population residing in the county is literate only in the same non-English language, as determined by the department of health human services (HHS); the counties that meet this 10 percent standard, as determined by HHS, are found at http://cciio.cms.gov/resources/factsheets/clas-data.html and any necessary changes to this list are posted by HHS annually.
L. “Day or Days” shall be interpreted as follows, unless otherwise specified:
(1) 1-5 days means only working days and excludes weekends and state holidays; and
(2) 6 days or more means calendar days, including weekends and holidays.
M. “Deductible” means a fixed dollar amount that the covered person may be required to pay during the benefit period before the health care insurer begins payment for covered benefits; plans may have both individual and family deductibles and separate deductibles for specific services.
N. “Expedited review” means a review with a shortened timeline, as described in sections 22.214.171.124 NMAC, 126.96.36.199 NMAC, 188.8.131.52 NMAC, 184.108.40.206 NMAC, and 220.127.116.11 NMAC, which is required in urgent care situations or when the grievant is receiving an on-going course of treatment which the health care insurer seeks to reduce or terminate.
O. “External review” means the external review conducted pursuant to this rule by the superintendent or by an IRO appointed by the superintendent, depending on the circumstances.
P. “Final adverse determination” means an adverse determination that has been upheld by a health care insurer at the conclusion of the internal review process.
Q. “Grievance” means an oral or written complaint submitted by or on behalf of a covered person regarding either an adverse determination or an administrative decision.
R. “Grievant” means a covered person or that person’s authorized representative, provider or other health care professional with knowledge of the covered person’s medical condition, acting on behalf of and with the covered person’s consent.
S. “Health benefits plan” means a health plan or a policy, contract, certificate or agreement offered or issued by a health care insurer or plan administrator to provide, deliver, arrange for, pay for or reimburse the costs of health care services, including a traditional fee-for-service health benefits plan and coverage provided by, through or on behalf of an entity that purchases health care benefits pursuant to the New Mexico Health Care Purchasing Act.
T. “Health care insurer” means a person that has a valid certificate of authority in good standing issued pursuant to the Insurance Code to act as an insurer, health maintenance organization, non-profit health benefits plan, fraternal benefit society, vision plan or pre-paid dental plan.
U. “Health care professional” means a physician or other health care practitioner, including a pharmacist, who is licensed, certified, or otherwise authorized by the state to provide health care services consistent with state law.
V. “Health care services” means services, supplies and procedures for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease, and includes, to the extent offered by the health benefits plan, physical and mental health services, including community-based mental health services, and services for developmental disability or developmental delay.
W. “Hearing officer, independent co-hearing officer (ICO)” means a health care or other professional licensed to practice medicine or another profession who is willing to assist the superintendent as a hearing officer in external review hearings.
X. “Independent review organization (IRO)” means an entity that is appointed by the superintendent to conduct independent external reviews of adverse determinations and final adverse determinations pursuant to this rule; and which renders an independent and impartial decision.
Y. “Initial determination” means a formal written disposition by a health care insurer affecting a covered person’s rights to benefits, including full or partial denial of a claim or request for coverage or its initial administrative decision.
Z. “Managed health care bureau (MHCB)” means the managed health care bureau within the office of the superintendent of insurance.
AA. “Medical necessity or medically necessary” means health care services determined by a provider, in consultation with the health care insurer, to be appropriate or necessary, according to any applicable generally accepted principles and practices of good medical care or practice guidelines developed by the federal government, national or professional medical societies, boards and associations, or any applicable clinical protocols or practice guidelines developed by the health care insurer consistent with such federal, national, and professional practice guidelines, for the diagnosis, or direct care and treatment of a physical, behavioral, or mental health condition, illness, injury or disease.
BB. “Office of the superintendent of insurance (OSI)” means the office of the superintendent or its staff.
CC. “Post-service claim” means a claim submitted to a health care insurer by or on behalf of a covered person after health care services have been provided to the covered person.
DD. “Prior authorization” (also called pre-certification) means a pre-service determination made by a health care insurer regarding a member’s eligibility for services, medical necessity, benefit coverage, location or appropriateness of services, pursuant to the terms of the health care plan.
EE. “Prospective review” means utilization review conducted prior to provision of health care services in accordance with a health care insurer’s requirement that the services be approved in advance.
FF. “Provider” means a duly licensed hospital or other licensed facility, physician or other health care professional authorized to furnish health care services within the scope of their license.
GG. “Rescission of coverage” means a cancellation or discontinuance of coverage that has retroactive effect; a cancellation or discontinuance of coverage is not a rescission if:
(1) the cancellation or discontinuance of coverage has only a prospective effect; or
(2) the cancellation or discontinuance of coverage is effective retroactively to the extent it is attributable to a failure to timely pay required premiums or contributions towards the cost of coverage; or
(3) the cancellation or discontinuance of coverage is initiated by the covered person or the covered person’s authorized representative and the employer or health care insurer did not, directly or indirectly, take action to influence the covered person’s decision or otherwise retaliate against, interfere with, coerce, threaten or intimidate the covered person; or
(4) the cancellation or discontinuance is initiated by the health insurance exchange.
HH. “Retrospective review” means utilization review that is not conducted prior to provision of health care services.
II. “Summary of benefits” means the written materials required by Section 59A-57-4 NMSA 1978 to be given to the grievant by the health care insurer or group contract holder.
JJ. “Superintendent” means the superintendent of insurance, or the office of the superintendent of insurance.
KK. “Termination of coverage” means the cancellation or non-renewal of coverage provided by a health care insurer to a grievant, but does not include a voluntary termination by a grievant, termination initiated by the health insurance exchange, or termination of a health benefits plan that does not contain a renewal provision.
LL. “Traditional fee-for-service indemnity benefit” means a fee-for-service indemnity benefit, not associated with any financial incentives that encourage covered person to utilize preferred providers, to follow pre-authorization rules, to utilize prescription drug formularies, or other cost-saving procedures to obtain prescription drugs, or to otherwise comply with a plan’s incentive program to lower cost and improve quality, regardless of whether the benefit is based on an indemnity form of reimbursement for services.
MM. “Uniform standards” means all generally accepted practice guidelines, evidence-based practice guidelines, or practice guidelines developed by the federal government, or national and professional medical societies, boards and associations; and any applicable clinical review criteria, policies, practice guidelines, or protocols developed by the health care insurer consistent with the federal, national and professional practice guidelines that are used by a health care insurer in determining whether to certify or deny a requested health care service.
NN. “Urgent care situation” means a situation in which the decision regarding certification of coverage shall be expedited because:
(1) the life or health of a covered person would otherwise be jeopardized;
(2) the covered person’s ability to regain maximum function would otherwise be jeopardized;
(3) the physician with knowledge of the covered person’s medical condition reasonably requests an expedited decision;
(4) in the opinion of the physician with knowledge of the covered person’s medical condition, delay would subject the covered person to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim;
(5) the medical exigencies of the case require an expedited decision, or
(6) the covered person’s claim otherwise involves urgent care.
OO. “Utilization review” means a set of formal techniques designed to monitor the use of or evaluate the medical necessity, appropriateness, efficacy or efficiency of health care services, procedures, providers, or facilities.