How to appeal a health insurance denial in New Mexico
The short answer
Start with your plan’s own appeal. If the plan says no again, you can usually ask an independent reviewer to decide. New Mexico lets you ask an independent reviewer to decide, through New Mexico Office of Superintendent of Insurance. The deadline to ask: within four months from receipt of the written notice of the final internal review decision (the Superintendent can extend this for good cause).
Does this apply to you? State external review covers plans regulated by New Mexico: individual and Marketplace plans, and job-based plans your employer bought from an insurer. Many large employers are self-funded; their plans follow the federal external review process, and state law usually does not apply (29 CFR 2590.715-2719(c)(1)). Medicare, Medicaid, TRICARE and federal employee plans have their own appeals: see the plan guides.
External review in New Mexico
Within four months from receipt of the written notice of the final internal review decision (the Superintendent can extend this for good cause)
Call the Managed Health Care Bureau (505-827-4601 or 855-427-5674) and send a complaint form with a signed medical release and a statement from your treating physician. The reviewer decides within 72 hours of being appointed. In urgent cases you can request the expedited external review right away.
Free
State-regulated plans (insurance bought in New Mexico or through an employer that buys insurance). Self-funded employer plans use the federal process.
File with OSI's Managed Health Care Bureau using the online Managed Healthcare Complaint Form, email to mhcb.grievance@osi.nm.gov (subject: external review request), fax 505-827-4253, or mail. Include all prior decision notices and a signed medical-records release. Rescissions and denials that do not involve medical judgment go to an OSI review or hearing instead of an independent review organization. A standard review is decided within 20 days, and you can ask the Superintendent for a hearing within 20 days of the decision. Plans under the NM Health Care Purchasing Act (public employers) must first complete an internal panel review.
Who to contact
Before external review: the internal appeal
External review usually comes after your plan’s own appeal. The deadline for that first appeal depends on the type of plan:
- Employer plan: 180 days from the day you receive the denial notice
- Marketplace plan: 180 days from the day you receive the denial notice
- Medicare Advantage: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Medicare Part D: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Original Medicare: 120 days from when you receive the notice (counted as 125 days from the notice date)
- Medicaid: 60 days from the date printed on the denial notice
- FEHB (federal employees): 6 months from the date of the denial notice
- TRICARE: Mail within 90 days after the date of the denial notice
Questions people ask
How long do I have to ask for an external review in New Mexico?
Within four months from receipt of the written notice of the final internal review decision (the Superintendent can extend this for good cause)
Can I get a fast external review in New Mexico?
Call the Managed Health Care Bureau (505-827-4601 or 855-427-5674) and send a complaint form with a signed medical release and a statement from your treating physician. The reviewer decides within 72 hours of being appointed. In urgent cases you can request the expedited external review right away.
Does external review cost anything in New Mexico?
Free
Do New Mexico’s rules apply to my job-based plan?
Only if the plan is fully insured, meaning your employer bought a policy from an insurance company. Self-funded employer plans generally follow the federal external review process instead. Your Summary Plan Description or HR benefits team can tell you which kind you have.
Sources
- 13.10.17.21 NMAC, Initiating an IRO review
a grievant must file a written request for an IRO review within four months from receipt of the written notice of the final internal review decision unless extended by the superintendent for good cause shown
- 13.10.17.19 NMAC, IRO review of an adverse determination
may request an external review by an impartial IRO appointed by the superintendent at no cost to the grievant
- 13.10.17.22 NMAC, Timeframes and processes for IRO review
but in no case later than 72 hours after appointment by the superintendent
This page is general information about appeal rules in the United States. It is not legal or medical advice. Rules can change, and your plan’s documents and your denial letter control the dates that apply to you.