Managed Health Care Bureau

The Managed Health Care Bureau of Office of Superintendent of Insurance assists the Superintendent in administering and enforcing the New Mexico Insurance Code, Patient Protection Act and Office of Superintendent of Insurance rules related to commercial managed health care insurance in New Mexico. The Bureau’s key focus is to assist managed health care consumers and enrollees in understanding their rights to appeal coverage and claim denials of requested health care services under a health maintenance organization (HMO) or preferred provider organization (PPO) product. Such appeals and complaints are rights afforded to every commercial managed health care enrollee under the New Mexico Patient Protection Act to include quality and access to care.

The Bureau also promotes the education of these rights by conducting outreach presentations throughout New Mexico. Our staff will come and deliver outreach presentation to your group.

We also assist health care providers with certain issues related to managed health care insurer operations and specifically, the timely payment of clean claims.

Grievance Procedure Rules

Information for IROs

Tips

  • If a problem should arise your first step should be to contact your insurer.

  • Document verbal correspondence; get the name of the person providing you information, write down the main issues and the response and the date and time the conversation occurred.

  • Do not hesitate to ask your plan any questions especially, If something is the slightest bit confusing, unclear or you just don’t understand.

  • Review your Summary of Benefit Handbook to understand your appeal rights and deadlines.

  • If you are going to seek out of net work care ask your plan what the reasonable and customary charges for the care you are going to receive and ask the provider the same question. (See example of balanced billing)

  • Ask the cost of out of pocket expenses.