Navigate Your Medical Care: Appeals and Grievances

Some health services need approval from BCBSNM before you get care. This is called a "prior authorization." If a service isn't approved, it won't be covered by BCBSNM. Usually, your health providers handle this before treatment. However, always a good idea to check. You and your provider can still decide to go ahead with the service, but you may have to pay if it is not approved.

Your doctor or an office staff member may request a medical prior authorization by phone, fax, or mail. Please visit our Contact Us page for more information. 

If coverage for an item or medical care is denied and you think it should be covered, you can file an appeal.

• You will get a written response to your appeal as quickly as your case requires. The response will be:
  • No later than 30 calendar days after we receive your appeal for medical service authorization.
  • No later than 60 calendar days after we receive your appeal for payment.
• We may add to the time frame by up to 14 calendar days if you ask for an extension.

You may request a medical appeal by fax or mail. Please visit our Contact Us page for more information. 

• You can ask for an expedited (fast) appeal if:
  • Coverage was denied and your health requires a quick response.
  • You think that your covered care in a skilled nursing facility, home health or comprehensive outpatient rehabilitation facility is ending too soon.
• You will get a written response to your expedited appeal as quickly as your case requires based on your health status. This will be no later than 72 hours after we receive your expedited appeal.
• We may extend the time frame by up to 14 calendar days if you ask for an extension.
• If there’s a need for more information and the delay is in your best interest, the appeal can take longer. When we extend the deadline, we will let you know right away the reason(s) for the delay in writing.

You may request an expedited medical appeal by phone or fax. Please visit our Contact Us page for more information.  

You can file a grievance if you have a complaint about:

• The quality of care you receive.
• The timeliness of service.
• Any other concern (except for the coverage or payment issues listed above).

If you have an issue related to what is covered for medical services, or if you or your appointed representative wish to file a grievance, please call us. Visit our Contact Us page. You may also file a grievance by fax or mail.

Important: You must file a grievance with us no later than 60 days after the event or incident in question.

You may also contact Customer Service if you want to know about the number of appeals, grievances or exceptions filed with the plan.

Here are examples of reasons you may file a grievance:

• You feel that you’re being encouraged to leave (disenroll from) our plan.
• Concerns with customer service.
• Long wait times for a pharmacy or medical office.
• Disrespectful or rude behavior by pharmacists or medical staff.
• Cleanliness or condition of pharmacy or medical office.
• You do not agree with our decision not to expedite your request for an expedited coverage determination or redetermination.
• You believe our notices and other written materials are hard to understand.
• The plan sponsor (BCBSNM) failed to give you a decision within the required time frame.
• BCBSNM did not forward your appeal case for an independent review if we didn’t give you a decision within the required time frame.
• We did not provide required notices, and/or the notices did not comply with Centers for Medicare & Medicaid Services (CMS) standards.

Resolving Your Concerns

A grievance must be filed with us no later than 60 days after the event or incident in question.

Resolve by Phone
We try to resolve any complaint you have over the phone. If Customer Service cannot resolve your concern over the phone, we have a formal process to review your complaints. We have made this process easy to follow so you will get a timely response.

• If your concern is not resolved at the time of your first phone call, it will be forwarded to a grievance coordinator to be resolved.
• If your grievance involves the quality of the care you received, you will get a written response. 
• You will be sent a written response as quickly as your case requires based on your health status. This will be no later than 30 calendar days after we receive your complaint. 
• We may add to the time frame by up to 14 calendar days if you request an extension.
• If there’s a need for more information and the delay is in your best interest, the reply can take longer. When we extend the deadline, we will let you know right away the reason(s) for the delay in writing.

By Mail
You may file a grievance in writing by sending a letter by mail or by fax telling us about your grievance.

You may choose someone to act on your behalf. This is called “an appointment of representative.”

• This person can be a relative, friend, sponsor, lawyer or a doctor.
• A court may also appoint someone.
• You and the person you choose must complete, date, and sign a representative statement.
• The notice or request may also be made in a written letter. If you are legally not of sound mind or are incapacitated, the representative can complete and sign the statement.
• The representative needs to have the correct legal papers or legal authority to sign for you.
• If you choose a lawyer, only you need to sign the representative statement.
• The representative statement must include your name and Medicare claim number.

Forms you can use:

• CMS Appointment of Representative form
  
• Social Security Administration form

What if you need a drug that isn’t covered? There are things you can do to request an exception. Find out how coverage decisions are made. Visit Drug Coverage Determinations, Appeals and Grievances.