New Mexico commercial plans: Provider grievance process
In accordance with New Mexico law, providers have the right to file a grievance about health care insurer operations, termination from a health plan, credentialing and timely claims payment.
Health plan operation grievances include grievances about quality of care or network adequacy issues. Grievances about denial of a specific member’s access to a benefit should be filed pursuant to the member grievance plan found in the member’s health plan language. You can send provider grievances to:
Attn: Provider Contract Appeals
P.O. Box 31376
Salt Lake City, UT 84131-0376
Here’s how the grievance process works:
At the first level of an operational grievance, providers have the right to present their concerns to a committee responsible for the area addressed by the grievance. The substance of the first-level grievance will also be conveyed to the health plan’s governing body.
The health plan’s governing body must be provided the opportunity to direct the committee’s review and resolution of the grievance. The governing body may also dictate who serves on the grievance review committee. The health plan must issue a written decision to the provider within 20 days of receiving the operational grievance and all relevant information.
Termination for cause
For terminations based on cause, the health plan must allow the provider to appear in person before a fair hearing officer or committee appointed by the health plan. Providers have the right to:
Present a case to the fair hearing officer or committee
Submit supporting materials to the hearing officer or committee
Ask questions of any representative of the health plan
Be represented by an attorney or other person of the provider’s choice
Ask for an expedited hearing where the health plan has not provided written notice of the termination to the provider because the health plan has reason to believe that further care by the provider would result in imminent and significant harm to members
The health plan must issue a written decision within 20 days of the fair hearing and forward a copy of the decision to the provider using the method of written communication chosen by the provider.
When the quality of care provided to members is the basis for termination and the health plan has reason to believe that further care by the provider would result in imminent and significant harm to members, the health plan is not required to provide advance written notice of termination for cause.
For all other terminations, the health plan will provide a written explanation to the provider at least 30 days in advance of the termination.
Appeal rights for operational grievances and terminations
If the provider is dissatisfied with the results of the plan’s internal grievance procedure, they may file a written request for review with the superintendent within 30 days from receipt of the written decision of the managed health care plan (MHCP) concerning the grievance.
Complaints to the New Mexico Office of the Superintendent of Insurance should be filed with the New Mexico Office of Superintendent of Insurance. After appropriate investigation of a provider complaint, the superintendent may schedule a hearing.
In accordance with New Mexico law, providers also have the right to grieve the failure of the health plan to pay clean claims. To initiate an internal review, providers should file an inquiry with the health plan about the status of the claim as a clean claim and why the claim has not been paid. The health plan will respond to this inquiry in writing within 15 days of receiving the inquiry. The health plan’s response will explain the plan’s failure or refusal to pay, or the expected date of payment if payment is pending.
If a provider is not satisfied with the outcome of this grievance, the provider may file a complaint with the Office of Superintendent of Insurance. The provider may file a complaint if the health plan doesn’t respond or the issue hasn’t been resolved at the internal level within 45 days of initiation of the claims payment grievance.