1. A. Record required. The health care insurer shall maintain a grievance register to record all grievances received and handled during the calendar year. The register shall be maintained in a manner that is reasonably clear and accessible to the superintendent.

2. B. Contents. For each grievance received, the grievance register shall:

   1. (1) assign a grievance number;
   2. (2) indicate whether the grievance is an adverse determination or administrative grievance, or a combination of both;
   3. (3) state the date, and for an expedited review, the time the grievance was received;
   4. (4) state the name and address of the grievant, if different from the covered person for whom the grievance was made;
   5. (5) identify by name and member number the covered person making the grievance or for whom the grievance was made;
   6. (6) indicate whether the grievant’s coverage is provided by an entity that purchases or is authorized to purchase health care benefits pursuant to the New Mexico Health Care Purchasing Act, the medicaid program, or a commercial health care insurer;
   7. (7) identify the health insurance policy number and the group if the policy is a group policy;
   8. (8) identify the individual employee of the health care insurer to whom the grievance was made;
   9. (9) describe the grievance;
   10. (10) for adverse determination grievances, indicate whether the grievance received was an expedited or a standard review;
   11. (11) indicate at what level the grievance was resolved and what the actual outcome was; and
   12. (12) state the date the grievance was resolved and the date the grievant was notified of the outcome.
3. C. Annual report. Health care insurers shall annually submit to the superintendent a compilation of data extracted from the grievance register on or before March 1. The specific data to be submitted will be listed in the MHCB’s section of the website of the OSI.
4. D. Retention. The health care insurer shall maintain such records for at least six years.
5. E. Submittal. The health care insurer shall submit information regarding all grievances involving quality of care issues to the health care insurer’s continuous quality improvement committee and to the superintendent; and shall document the qualifications and background of the continuous quality improvement committee members.

6. F. Examination. The health care insurer shall make such record available for examination upon request and provide such documents free of charge to a grievant, or to state or federal agency officials subject to any applicable federal or state patient confidentiality laws regarding disclosure of personally identifiable health information.

   HISTORY OF 13.10.17 NMAC:

   NMAC history:

   13.10.17 NMAC, Grievance Procedures, effective 7/1/2000.

   13.10.17 NMAC, Grievance Procedures, effective 5/3/2004.

   13.10.17 NMAC, Grievance Procedures, effective 1/1/2016.

   13.10.17 NMAC, Grievance Procedures, effective 1/1/2017.

   History of repealed material:

   13 NMAC 10.17, Grievance Procedure for Enrollees Covered by Risk Management Division, filed 11/02/1998 - Repealed effective 7/1/2000.

   13.10.17 NMAC, Grievance Procedures, filed 6/14/2000 - Repealed effective 5/3/2004.

   13.10.17 NMAC, Grievance Procedures, filed 3/12/2004 - Repealed effective 1/1/2016.

   13.10.17 NMAC, Grievance Procedures, filed 11/17/2015 - Repealed effective 1/1/2017.

[13.10.17.34 NMAC - Rp, 13.10.17.12 NMAC, 1/1/2017]