Source: http://coveragerights.org/new-mexico/
Timestamp: 2019-04-22 14:04:18+00:00

Document:
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). This means you can ask your insurer to conduct a full and fair review of its decision.
You are experiencing a medical emergency.
If you believe you qualify for an expedited internal review, contact your insurer immediately and ask for instructions on how to request one.
Your health plan should also offer a second level internal review. 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.
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. 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. 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.
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. If you requested an expedited internal review, you should receive a decision within 72 hours of your request. If the insurer fails to meet these timeframes, it must approve your claim request.
During an external review, an independent third party reviews your insurer’s decision. 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.
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.
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.
Any new information or documentation not included with your request for an internal review.
The external review process should take no more than 45 days. If you requested an expedited external review, the process should take no longer than 72 hours.
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.
What you think would be a fair resolution.
Copies of any supporting documents from your healthcare provider.
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.
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.
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.
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.
 N.M. Code R. § 13.10.17.18 (2016).
 N.M. Code R. § 13.10.17.17 (2016).
 N.M. Code R. § 13.10.17.19 (2016).
 N.M. Code R. § 13.10.17.20 (2016).
 N.M. Code R. § 13.10.17.24 (2016).
 N.M. Code R. § 13.10.17.25 (2016).
 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).
 N.M. Code R. § 13.10.17.27 (2016).
 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).
 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).
 Consumer & Constituent Complaint Form, Consumer & Family Advocacy Serv. Div., http://www.nmag.gov/uploads/files/ComplaintForms/ConsumerComplaintForm.pdf (last visited Nov. 27, 2016).

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