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Insurance Bureaus >> Consumer Assistance Bureau >> Managed Healthcare Complaint Form

 

Managed Healthcare Complaint Form

 

The Managed Health Care Bureau will investigate this complaint to determine if there are any violations of the New Mexico
Insurance Code, Managed Health Care Rule or insurance policy language.

If you prefer to download the complaint form, click here * designates required field
   
 Customer Contact Information (The name on your bill or account)
* Customer Name: * Phone Number:
* E-Mail Address:  
       
Street Address
* Street: * City:
* State: * Zip:
       
Type of Complaint
Type of Complaint: Member Provider Other  
ID #: Group #:
Name of Employer:    
Type of Healthcare Plan: Individual
Medicaid
Medicare Supplement Plan
PPO
Not sure
Group
Self-funded
NM School Authority
NM Retiree Authority
 
       
Insurance Company
* Name of Insurance Company: Lovelace Presbyterian Blue Cross Blue Shield of NM
  Amerigroup of New Mexico Molina Other
       
Reason for Complaint
Payment of Fees Treatment
Physicians Issue Referral/Prior Authorization
Emergency Room Administrative Issue Other:
       
Have you started the appeal process?
If yes, at what level is your complaint in the internal health plans process?  
Medical Director

Internal Panel Reviewed

Exhausted Internal Review, Requesting and External Review
 
Statement of Facts
* Explain the details of your complaint. 

Email copies of any documents you believe will assist us.

PLEASE EMAIL US A COPY OF YOUR BENEFITS BOOKLET
Please submit relevant documentation such as copies of the bill(s) in dispute, cancelled checks, copy of your policy, receipts, etc.
If you prefer, you may send additional documentation via email: osi.consumer@state.nm.us or via fax: 505-827-3833
Explain what you feel would be a fair resolution of this matter.

(What do you think the company should
do to make this situation right?)
       
Supporting Documents

I authorize (Insurance Company Name) to release all medical records, including nonpublic personal health information and nonpublic personal financial information, which are related to this complaint, to the Office of Superintendent of Insurance. I authorize the release of such information, as necessary for the investigation, evaluation and resolution of my complaint, as allowed by law and on a need-to-know basis. I understand that my health insurer protects such information from unauthorized disclosure under federal and state law and other Office of Superintendent of Insurance rules and regulations. I understand that the Office of Superintendent of Insurance does not act as an attorney for private citizens.”

   

It is very important to make sure that we receive your submission properly.  When your form submission is completed correctly, you will receive a page with your form submission information.

If you do not receive this page, and instead encounter an error page, please read it carefully, go back on your browser, correct your submission, and resubmit. If you have any questions, whatsoever, please contact us here.