New Mexico provider grievance plan for UnitedHealthcare commercial plans
- In accordance with New Mexico law, all providers have the right to file a grievance for the following concerns:
- Credentialing deadlines
- Claim payment amount or timing
- Network adequacy, including participation determinations based on network composition
- Network composition including provider qualifications
- Utilization management practices
- Surprise billing reimbursement amount, rate or timing
- Discrimination
As part of their grievance related to the concerns identified above, non-participating providers must assert and explain that our act or practice directly impacted them or one of their patients.
Participating providers may also file a grievance for the following concerns:
- Claim submission requirements or compliance
- Provider contract construction or compliance
- Patient care standards or access to care
- Termination
- Operation of the plan, including compliance with any law enforceable by the superintendent, or of any directive of the superintendent
How the grievance process works
- Timeline to file: A provider has 90 days from the incident, which is the subject of the grievance, to file a grievance
- Filing procedures and response: A provider should submit a written grievance electronically or manually. We will send written acknowledgment of the grievance to the provider within 5 days of its receipt using the provider’s preferred communication method.
- Request for supplemental information: We may need supplemental information pertinent to the resolution of a grievance.
- We will request the information within 10 days of receipt of the grievance. We will require the provider to submit the information within 10 days.
- Review panel: A review panel comprised of multiple members, at least 1 of whom is in a position of authority over the operations that are the subject of the grievance, will review and decide upon the provider’s grievance.
- If the grievance raises a quality-of-care concern the panel will include a New Mexico-licensed medical professional who practices in the general area of concern
- A New Mexico-licensed physician will be included on a review panel considering complex quality-of-care concerns
- No person with a conflict of interest will participate in a decision to resolve a grievance. Employment with the carrier, standing alone, does not present a conflict of interest.
- Response: We will provide a written response to a grievance using the provider’s preferred method of communication within 45 days of receipt of the grievance, receipt of supplemental information requested to resolve the grievance or the due date for submission of any requested supplemental information. The response will include:
- The name(s), title(s) and qualification(s) of each person who participated in the grievance decision
- A statement of issue(s) decided and of the ultimate decision(s)
- A clear and complete explanation of the rationale for the decision and a summary of the evidence relied upon to support the decision
- A summary of any proposed remedial action
- Information on the provider’s appeal rights
- Extension of deadlines: We and the provider may agree, in a documented communication, to extend any deadline imposed by this grievance plan
- Presentation of evidence: A provider may present oral or documentary evidence to the assigned grievance panel
- Bundled or group grievances: A provider may submit multiple related grievances simultaneously provided the grievances are not unduly duplicative or repetitive. A group of providers may assert a single grievance on behalf of multiple providers.
Terminations other than for cause
If a termination is not for cause, we will give the provider written notice at least 60 days before the effective date of termination. The notice will:
- Be communicated in writing via the format preferred by the provider
- Contain an explanation of the termination
Terminations for cause
For terminations based on cause, we will provide a fair hearing process that provides these minimum rights and protections:
- The right of the provider to appear in person at a hearing before the deciding panel
- The right of the provider to present testimonial or documentary evidence at the hearing
- The right of the provider to call witnesses and cross-examine any witness
- The right of the provider to be represented by an attorney or by any other person of the provider’s choice
- The right to an expedited hearing within 14 days of the termination in those instances where we have not provided advance written notice of termination and the termination could result in imminent and significant harm to a covered person
- A written decision within 20 days after the hearing, contemporaneously delivered via the provider’s preferred method of communication
- If a group of providers is terminated for cause, each provider in the group has an individual right to a hearing. However, if any one of the providers in the group submits a grievance relating to the termination, we will provide each similarly situated provider in the group with a notice of hearing, and each provider who receives such notice will be bound by our determination subject to any appeal rights.
Where to direct your concerns
If you have not received a notification with specific contact information, please direct your concerns to:
Operational grievances, including:
- Claim payment amount or timing
- Claim submission requirements or compliance
- Utilization management practices
- Patient care standards or access to care
- Surprise billing reimbursement amount, rate or timing
- Discrimination
- Operation of the plan, including compliance with any law enforceable by the superintendent, or of any directive of the superintendent
Mail to:
UnitedHealthcare
Attn: PAO Appeals
P.O. Box 30559
Salt Lake City, UT 84130
Network grievances, including:
- Network adequacy, including participation determinations based on network composition
- Network composition including provider qualifications
- Provider contract construction or compliance
- Credentialing deadlines
- Terminations
Mail to:
UnitedHealthcare
Attn: Provider Contract Appeals
P.O. Box 31376
Salt Lake City, UT 84131-0376
Appeals
If a provider is not satisfied with the results of our internal grievance procedure for a grievance that pertains to an issue listed below, they may file a request for an external review with the superintendent in accordance with the requirements set forth in New Mexico Administrative Code, Section 13.10.16.10. The appeal must be filed no later than 30 days after receipt of our written decision or the deadline for our decision, whichever is earlier. The superintendent will only review a grievance that pertains to any of the following:
- An alleged violation of a law enforceable by the superintendent
- Alleged noncompliance with an order of the superintendent
- A termination based on a provider’s alleged failure to comply with a law or order enforceable by the superintendent
Providers may file an appeal with the New Mexico Office of Superintendent of Insurance.
Questions?
Contact your network management representative.
