N.M. Admin. Code § 8.352.3.9

Current through Register Vol. 35, No. 21, November 5, 2024

Section 8.352.3.9 - PROVIDER ADMINISTRATIVE HEARINGS

With the exception of referrals for credible allegations of fraud, HSD has established a hearing process for MAD fee-for-service (FFS) providers who disagree with its decision concerning his or her participation as a MAD provider, recoupment of overpayments due to a provider billing error, and the imposition of MAD sanctions. For the provider administrative hearing process concerning decisions on noncompliance with nursing facility (NF) or intermediate care facility for individuals with intellectual disabilities (ICF-IID) provider certification requirements also see hearing regulations promulgated by the department of health (DOH) and specific MAD New Mexico administrative code (NMAC) rules applicable to the provider. See 8.311.3 NMAC, 8.312.2 NMAC, and 8.313.3 NMAC for a detailed description of the appeals process for audit settlements. See 8.308.14 NMAC for a detailed description of the grievance and appeal process for resolving provider disputes between a HSD contracted managed care organization (MCO) and its contractor or subcontractor. For applicable rules for services and items provided through a MAD coordinated service contractor, see 8.349.2 NMAC.

A.Provider administrative hearing rights: The right to a provider administrative hearing includes the right to:

(1) be advised of the nature and availability of a provider administrative hearing;

(2) be represented by his or her authorized representative or legal counsel;

(3) have a provider administrative hearing which safeguards the provider's opportunity to present a case;

(4) have prompt notice and implementation of the final provider administrative hearing decision; and

(5) be advised that judicial review may be invoked to the extent such review is available under state law.

B.Notice of rights: Upon enrollment, a MAD provider receives written notice of provider administrative hearing rights along with any MAD action notice concerning provider participation agreement (PPA) termination, recoupment of overpayment due to provider billing error, or notice of sanction. This information includes a description of the method by which a provider administrative hearing may be requested and a statement that the provider's presentation may be made by the provider or by his or her authorized representative or legal counsel.

N.M. Admin. Code § 8.352.3.9

8.352.3.9 NMAC - N, 1-1-14