Whom to contact:

New Mexico Superintendent of Insurance, State Corporation Commission

Who can appeal:

You or your provider with written consent

What you can appeal:

Denials of coverage for services the health plan determines are not medically necessary or a coverage benefit.

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:

Completed request form, including a medical records release.

What you must pay:

No charge

What will happen:

1. The Division of Insurance will complete the external review within 20 working days or 72 hours for expedited reviews.
2. If the case is not accepted for an external review hearing, the Superintendent will notify the enrollee.
3. If the case is accepted, the Superintendent schedules the external hearing immediately.
4. A panel of independent hearing officers will hear the case. The panel will consist of two physicians and one attorney.
5. The panel will make a recommendation to the enrollee, health plan, and 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 the health plan and the grievant.
8. Both the grievant and the health plan may take the case to district court.

When you will get a decision:

20 days after receipt of the request for external review and all necessary documentation.

In urgent situations:

Within 72 hours for an emergency