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.

* designates required field
 Consumer 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 Termination Other  
ID #: Group #:
Name of Employer:    
Type of Healthcare Plan: Individual
Medicare Supplement Plan
Not sure
NM School Authority
NM Retiree Authority
Insurance Companys
* Name of Insurance Company: CHRISTUS Health Plan Presbyterian Blue Cross Blue Shield of NM
  NM Health Connections 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 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: or via fax: 505-827-4734
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.