Managed Health Care Review

The Bureau’s key focus is to assist managed health care consumers and subscribers understand their rights to a grievance process if they do not agree with their insurance company decision. The grievance process includes an appeal within the insurance company and then the right to a review by the MHCB. The types of matters that a consumer can appeal include premium payments, termination of coverage, claims, benefit denials, prior authorization denials, and denials of care. 

These appeal and grievance processes are rights afforded to every commercial managed health care subscriber under the New Mexico Patient Protection Act. 

The Bureau also promotes the education of these rights by conducting outreach presentations throughout New Mexico. Our staff will come and deliver outreach presentations to your group.  The New Mexico Office of Superintendent of Insurance also investigates health care provider complaints filed against health care insurers. The Superintendent can assist with grievances regarding provider termination, discrimination, credentialing, timely payment of claims and other provider concerns in regards to the operations of the health insurer or plan. 

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 Benefits and Coverage and Plan Booklet to better understand your appeal rights and timeframes. 
• If you are going to seek out of network care ask your plan what the reasonable and customary charges are for the care you are going to receive and ask the provider the same question. (See an example of balanced billing) 
• Ask the cost of out-of-pocket expenses. 

For members/patients needing assistance concerning the handling of a health insurance claim, filing an appeal or grievance, file a complaint with Managed Health Care. 

For health care provider complaints, file a complaint with Managed Health Care.  

For assistance with other entities not regulated by the Department, please refer to the following list of resources: 

• Policies Purchased in Another State –  Map to States & Jurisdictions 
• Health Plans for Military Personnel – Tricare Health Care Program 
• Federal Employee Health Benefits Program – Healthcare & Insurance, Office of Personnel Management 
• Medicaid – New Mexico Health Care Authority 
• Workers’ Compensation – New Mexico Workers Compensation Dispute Resolution 
• NM Healthcare Authority (Medicaid) 
  Medical Assistance Division
  P.O. Box 2348
  Santa Fe, NM 87504-2348 
  1-800-997-2583 
• Medicare
  

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Additional Resources

The Centers for Medicare and Medicaid (CMS) 
7500 Security Boulevard Review 
Baltimore, MD 21244-1850 
1-800-Medicare (1-800-633-4227) 

US Department of Labor:
http://www.dol.gov
https://www.dol.gov/agencies/ebsa/about-ebsa/about-us/what-we-do 
US Department of Labor (Self-Funded / ERISA) 
200 Constitution Ave NW 
Washington, DC 20210
1-866-487-2365

New Mexico Aging Long-term Care  

US Department of Labor ERISA (Employee Retirement Income Security Act)   

US Department of Labor COBRA (Continuation of Health Coverage)