Consumer Guide to External Review

New Mexico has two types of appeals processes – one for utilization issues (Adverse External Review), and a separate process for non-utilization issues (Administrative External Review).

New Mexico provides for an internal review, which consists of two steps with your health plan, prior to initiating the external review process.

The External Review Process:

Whom to contact: Office of Superintendent of Insurance,
Managed Health Care Bureau
1-855-4 ASK OSI (1-855-427-5674)
Who can appeal: You, your provider or representative with written consent
What you can appeal: Adverse: Denials of coverage for services the health plan determines are not medically
necessary or a covered benefit.

Administrative: Regarding any aspect of a health benefits plan other than a request for health
care services, including but not limited to:
  • Administrative practices of the health care insurer that affects the availability, delivery, or quality of health care services;
  • Claims payment, handling or reimbursement for health care services; and
  • Terminations of coverage
When you can appeal: You must file within 20 working days after receiving the written notice from the health plan’s internal review. An expedited external review may be appealed concurrently with the internal appeal.
What to send: Click here for the required form or apply now.
What you must pay: No charge
What will happen: Adverse External Review
  1. Office of Superintendent of Insurance will complete the within fouty five working days or 72 hours for expedited reviews unless otherwise determined by the Superintendent.
  2. If the case is not accepted for an external review hearing, the Superintendent will notify the enrollee.
  3. If the hearing is granted by the Superintendent an external hearing will be scheduled.
  4. A panel of independent hearing officers will hear the case. The panel may consist of up to two physicians and one attorney.
  5. The panel will make a recommendation to the Superintendent after the hearing.
  6. The Superintendent will evaluate the panel’s recommendation and make a decision based on the evidence and the panel's recommendation and issue an appropriate order.
  7. The order is binding on both the health plan and the grievant.
  8. Both the grievant and the health plan may take the case to District Court.
Administrative External Review
  1. Office of Superintendent of Insurance shall review the documents submitted by the health care insurer and the grievant and may conduct an investigation or inquiry or consult with the grievant, as appropriate.
  2. The Superintendent shall issue a written decision on the administrative grievance within twenty (20) working days of receipt of the complete request for external review.

1120 Paseo de Peralta | Santa Fe NM 87501 | 1-855-4-ASK-OSI | Copyright © 2019 - All Rights Reserved - OSI