Consumer Guide to Filing an Appeal

Consumer Guide to Filing an Appeal

Whom to contact: Office of Superintendent of Insurance,
Managed Health Care Bureau
1-855-4 ASK OSI (1-855-427-5674)
(505)827-3928
Who can appeal: You, your provider or representative with the 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 to file a complaint. To expedite the process please submit copies of all documents issued by the medical insurance company regarding your grievance and a copy of the front and back of your medical insurance card.
What you must pay: No charge
What will happen: Adverse External Review

  1. Office of Superintendent of Insurance will complete the within forty-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 the 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.