Compliance Corner
What does New Mexico law spell out for the workers’ compensation utilization review process? Simply Research subscribers have that information at their fingertips, but we highlight some key points here.
Referral Process
(a) Any party may refer a claim to the WCA for utilization review by the WCA or its contractor, if any, by submitting the appropriate form to the WCA medical cost containment bureau. The form is located on the agency website.
(b) A utilization review request for pre-admission review of hospital admissions, except for emergency services, shall also follow this same referral and procedural process.
(c) Within 20 days of receiving a referral and all supporting documentation, the medical cost containment bureau shall notify the parties of its decision either accepting or denying the referral. The medical cost containment bureau may assign approved cases to the WCA’s contractor.
(d) Any party who objects to the decision of the medical cost containment bureau shall notify the WCA of its objection by filing an application to the director not later than 15 days from service of the decision.
Procedures
(a) Utilization review shall consider only the medical reasonableness, clinical necessity, efficiency and quality of the treatment under review.
(b) Only one treatment is appropriate for utilization review.
(c) Utilization review shall not include issues of compensability, including:
(i) the causal relationship between the treatment under review and the worker’s work-related injury;
(ii) whether the worker is disabled; and
(iii) whether the worker is at maximum medical improvement.
(d) If the medical cost containment bureau or its contractor requests additional information, the parties shall provide the requested information within 15 days. The WCA shall issue its utilization review decision within 60 days of receiving all necessary documentation.
(e) The WCA in its sole discretion may assign a claim to its contractor for peer review. Peer review shall only be conducted by a licensed healthcare provider who is in a similar field or equivalent discipline as the provider whose service is being reviewed. Peer review shall be independent and the physician or health care provider should not have prior involvement in the worker’s care or treatment.
(f) The medical cost containment bureau shall communicate the utilization review findings in writing with a copy to all parties. The WCA may adopt the findings of its contractor after utilization review.
(g) Any party who objects to the utilization review findings shall file an application to director within 15 days from service of the utilization review findings. If an application is not filed within 15 days, the utilization review findings shall become binding on the parties.
(h) The director may set a utilization review matter for hearing. An order issued by the director after hearing or receipt of an application to director is final and binding on the parties.
