New Mexico

My insurer refuses to cover my prescribed treatment. What can I do?

If your insurer denies your coverage, you can challenge your insurer’s decision by completing the following steps in order:

  • Request a first and second level internal review;
  • Request an external review; and
  • File a complaint.

 If I have a group health plan, how do I request an internal review?

If you have a group health plan and your insurer denies your claim, you have the right to two levels of internal review (sometimes referred to as an internal appeal).[1] This means you can ask your insurer to conduct a full and fair review of its decision.

First level internal review

To request the first level review, you should do the following:

  • Review the determination letter. Your insurer should have sent you a determination letter to tell you that it would not cover your claim. Review this document so you can understand why your insurer denied your claim and how you can appeal the denial.
  • Collect information. In addition to the determination letter, collect all documents that your insurer sent to you, including your insurance policy and your insurer’s medical necessity criteria. “Medical necessity criteria” refers to your insurer’s policy for determining whether a treatment or service is necessary for your condition.
  • Request documents. If your insurer did not send you the determination letter, your policy, the medical necessity criteria, or instructions and forms for filing an appeal, call your insurer and request these documents.
  • Call your health care provider’s office. Contact your health care provider’s office to ask for help with the appeals process. Someone in his or her office might help you fill out the forms to request an appeal and draft a strong appeal letter.
  • Submit the appeal request. You or someone in your health care provider’s office should submit the appeal forms along with the letter from your health care provider and any additional information that your insurer requested. Be sure to follow your insurer’s instructions closely and make a copy for your own records of all documents you or your health care provider submitted to the insurer.
  • Request an expedited internal review, if applicable. You can request an expedited internal review if one of the following applies:
    • Waiting 30 to 60 days for your requested treatment would jeopardize your life, health, or ability to regain function;
    • Your health care provider requests an expedited decision from your health insurer;[2]
    • Your medical condition would result in severe pain that cannot be adequately managed without the requested treatment or service; or
    • You are experiencing a medical emergency.[3]

If you believe you qualify for an expedited internal review, contact your insurer immediately and ask for instructions on how to request one.[4]

  • Follow up. Follow up with your insurer regularly until you hear back. Be sure to keep a record of the name of any representative you speak with about the appeal, the date and time you spoke with that person, a confirmation number for the call, and a summary of your discussion.

Second level internal review

Your health plan should also offer a second level internal review.[5] This process is optional. Your insurer will contact you after denying your claim in the first level internal review to provide you instructions on the second level internal review.[6]

If you choose to request a second level internal review, the health insurer will select an internal review panel to review the insurer’s decision.[7] You have the right to attend the panel review hearing, present your case to the panel, submit any additional supporting information or documentation, ask questions of health care professionals on the panel, and be assisted or represented by a person of your choosing.[8] If your case is under expedited internal review and your health insurer is unable to contact you to ask if you want a second level internal review, the insurer will automatically convene a second level review panel.[9]

 How long should the internal reviews process take?

Both the first and second level internal review combined should take a maximum of 30 days if you have not yet received the requested service or treatment and a maximum of 60 days if you have received the service or treatment but are waiting for reimbursement.[10] If you requested an expedited internal review, you should receive a decision within 72 hours of your request.[11] If the insurer fails to meet these timeframes, it must approve your claim request.[12]

In which circumstances can I apply for an external review?

During an external review, an independent third party reviews your insurer’s decision.[13] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under New Mexico law, you are entitled to request an external review if your insurer denies your coverage after the internal review process.[14]

You can also request an expedited external review if your medical situation is urgent and waiting would jeopardize your health, life, or ability to function. You can also request an expedited external review at the same time that you request an expedited internal review.[15]

How do I request an external review?

You should submit your request for an external review to the New Mexico Office of Superintendent of Insurance (“Office”) within 120 days from when your insurer sent you the most recent decision.[16]

Information

You can find a copy of the external review request form here. You should include the following information with your request:

  • The name, address, and telephone number of the patient;
  • The type of complaint;
  • Identification number, group number, and name of employer;
  • The type of health care plan;
  • The name of the insurance company; and
  • Summary of your complaint.[17]

Supporting documents

You should also include the following supporting documents with your request:

  • A signed medical records release form (included in the external review form packet);
  • Any new information or documentation not included with your request for an internal review.

Submitting the external review

You can submit your request for an external review in the following ways:

  • By fax to (505) 827-6341
  • By email to grievance@state.nm.us (use the subject line “external review request”); or
  • By mail to the following address:

Superintendent of Insurance
Attn: Managed Health Care Bureau –
External Review Request
P.O. Box 1689
1120 Paseo de Peralta
Santa Fe, NM 87504-1689[18]

How long will the external review process take?

The external review process should take no more than 45 days.[19] If you requested an expedited external review, the process should take no longer than 72 hours.[20]

How do I file a complaint with the New Mexico Office of Superintendent of Insurance?

If you are a New Mexico resident, you have coverage through a managed health care insurer, and you believe your insurer did something illegal or unethical, you can file a complaint with the Office.

Complaint information

Your complaint should include the following information:

  • The name, address, telephone number, and email address of the insured;
  • The type of complaint;
  • The name of your employer and type of plan;
  • The name of the insurance company;
  • The reason for the complaint;
  • The level your claim has reached in the internal and external review processes;
  • The details of your complaint; and
  • What you think would be a fair resolution.[21]

Supporting documents

You should submit the following documents as supporting information with your complaint:

  • A copy of your benefits booklet;
  • A copy of your insurance policy;
  • A copy of all correspondence related to your claim;
  • A copy of your adverse benefit determination letter; and
  • Copies of any supporting documents from your healthcare provider.[22]

How to submit

You can submit your complaint and supporting documents in the following ways:

Office of Superintendent of Insurance
1120 Paseo de Peralta
Santa Fe, NM 87501[23]

What happens after the Office of Superintendent of Insurance receives my complaint?

The Office will contact your health insurer by mail or phone depending on the complexity of your claim. If it contacts your insurer by mail, the insurer must respond within 10 business days. Once the Office receives the insurer’s response, it will attempt to resolve the issue with your health insurer and will provide you with the results of its investigation.[24]

 How do I file a complaint with the New Mexico Attorney General’s Office?

If you are a New Mexico resident and your insurer denies your claim after the external review process, you can file a complaint with the New Mexico Attorney General’s Office. A copy of the complaint form can be found here.

Complaint information

Your complaint should include the following information:

  • The name, address, email address, and telephone number of the person filing the complaint (“Complainant”);
  • The name, address, and telephone number of the of insurance company;
  • What actions you have taken to resolve the issue;
  • The details of the complaint; and
  • What you consider to be a fair resolution.

Supporting documents

You should submit the following documents as supporting documents with your complaint:

  • A copy of your insurance card;
  • Copies of coverage denials or adverse benefit determinations from your insurer;
  • Copies of any determinations made by internal and external reviewers;
  • Any materials submitted with prior appeals and complaints;
  • Supporting documentation from your doctor;
  • A copy of your insurance policy; and
  • All responses from your insurer.[25]

How to submit

You can mail the complaint and supporting documents to the following address:

New Mexico Attorney General’s Office
Consumer and Family Advocacy Services Division
P.O. Drawer 1508
Santa Fe, NM 87504-1508[26]

 What happens after the Attorney General’s Office receives my complaint?

The Attorney General’s Office will investigate and may refer your complaint to the Office of Superintendent of Insurance for resolution if it determines that the Office of Superintendent of Insurance is better able to assist you with your complaint.

Who should I call if I have any questions about filing a complaint?

You can contact the New Mexico Attorney General’s Office at (866) 627-3249 or (505) 827-6000 or (505) 222-9100. The Office is open from 8:00 a.m. to 5:00 p.m., Monday through Friday.

You can contact the Office of Superintendent of Insurance at (505) 827-3928. The Office is open from 8:00 a.m. to 5:00 p.m., Monday through Friday.


[1] Appealing a Health Plan Decision, Healthcare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/appeals/ (last visited Nov. 27, 2016).

[2] N.M. Code R. § 13.10.17.18 (2016).

[3] Id.

[4] N.M. Code R. § 13.10.17.17 (2016).

[5] N.M. Code R. § 13.10.17.19 (2016).

[6] Id.

[7] N.M. Code R. § 13.10.17.20 (2016).

[8] Id.

[9] N.M. Code R. § 13.10.17.19 (2016).

[10] N.M. Code R. § 13.10.17.18 (2016).

[11] Id.

[12] Id.

[13] Appealing a Health Plan Decision: External Review, HealthCare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/external-review/ (last visited Nov. 27, 2016).

[14] N.M. Code R. § 13.10.17.24 (2016).

[15] Id.

[16] N.M. Code R. § 13.10.17.25 (2016).

[17] Complaint Form, N.M. Office of Superintendent of Ins., http://www.osi.state.nm.us/ManagedHealthCare/docs/Managed%20Healthcare%20Complaint%20Form.pdf (last visited Nov. 27, 2016).

[18] N.M. Code R. § 13.10.17.24 (2016).

[19] N.M. Code R. § 13.10.17.27 (2016).

[20] Id.

[21] Managed Healthcare Complaint Form, N.M. Office of Superintendent of Ins., http://www.osi.state.nm.us/consumer-assistance/forms/managed-healthcare.html (last visited Nov. 27, 2016).

[22] Id.

[23] How to File a Complaint, N.M. Office of Superintendent of Ins., http://www.osi.state.nm.us/ConsumerAssistance/consumercomplaint.aspx (last visited Nov. 27, 2016).

[24] Id.

[25] Complaint to Federal Government Agency: Patient, Legal Action Ctr., https://lac.org/wp-content/uploads/2016/04/10-Patient-Federal-Complaint.docx (last visited Oct. 17, 2016).

[26] Consumer & Constituent Complaint Form, Consumer & Family Advocacy Serv. Div., http://www.nmag.gov/uploads/files/ComplaintForms/ConsumerComplaintForm.pdf (last visited Nov. 27, 2016).