Resources

At Blue Cross and Blue Shield of New Mexico (BCBSNM), we are committed to ensuring that you get the health care you need. We also want to make sure your rights as a member are respected. Here are some resources to help you.



Advance health care directives are legal instructions. They include written instructions for health care and a power of attorney for health care.

These directives help if you become injured or too ill to make health care decisions on your own. Even though you may not be injured or ill now, you can decide how you want to handle these situations in the future.

Instructions for Health Care
These legal instructions state what to do if you become terminally ill or permanently unconscious. They say whether or not you want to be put on a life support system. They also say what kind of treatment you do and do not want. Instructions for health care are sometimes called a "Living Will."

Power of Attorney (POA) for Health Care
This power gives a person you choose the right to make health care decisions for you if you are unable to express your own wishes. This person should be someone you trust.

Learn more about Advance Directives in your Member Handbook pdf. Download a POA/Advance Health Care Directives form with instructions pdf.

If you have questions, speak with your care coordinator or call BCBSNM at 866-689-1523. If you are speech or hearing impaired, call TTY 711. You can also call the State of New Mexico Aging and Disability Resource Center at 800-432-2080.


At BCSBNM, we take great pride in helping you get the care you need. But if you have a complaint about how we handle any services provided to you, you can file an appeal or a grievance. The difference between an appeal and a grievance is explained below.

Appeal

An appeal is a request for review of an "Action" taken by BCBSNM about a service. An Action is when BCBSNM denies, delays, reduces, limits or stops a service. We will give you written notice of an Action. The notice will also give you instructions for filing an appeal.

Grievance

A grievance is a complaint. It says that you are dissatisfied about any matter or part of BCBSNM or its services other than an "Action." For example, you can file a grievance if you are not happy with a provider. Or, a grievance can be filed to complain about the quality of the provider network or any other service BCBSNM provides. All grievances are kept confidential.

How to File an Appeal or Grievance

You may make a complaint or file an appeal over the phone or in writing.

  • Call:
    If you want to file an appeal, call BCBSNM at 866-689-1523.

    If you have a grievance about BCBSNM or a provider, call Customer Service at 866-689-1523. If you are speech or hearing impaired, call TTY 711.

    BCBSNM Customer Service can help you file an appeal or grievance. They will get you in contact with the Centennial Care Appeals/Grievance Coordinator.
  • Write:
    You can also send a written appeal or grievance to:
    Centennial Care Appeal/Grievance Coordinator
    P.O. Box 27838
    Albuquerque, NM 87125-5520

Time Limits for Filing

There are time limits for filing an appeal or a grievance.

  • Filing an Appeal — You may file an appeal by phone or in writing within 90 calendar days of receipt of a denial letter from BCBSNM. You must also mail in your request for an appeal within 13 calendar days from calling.
  • Filing a Grievance — You may file a grievance by phone or in writing within 30 calendar days of the problem.

We will confirm that we received your request. BCBSNM has 30 calendar days from the receipt of your initial request to respond to your concern or resolve the appeal.

You can ask BCBSNM for more time or BCBSNM can ask the Human Services Department for more time if needed to explain or research the issue.

This is just a brief description of appeals and grievances. For more details, see the Member Handbook pdf.


Health care fraud has become a huge problem. It affects the health care industry and our nation. Fraud may cost the health care industry more than $220 billion each year.* It costs all of us in the long run.

Fraud can:

  • Raise health care costs
  • Tie up precious health care resources that are needed elsewhere
  • Lower consumer confidence in our health care system

If a provider commits fraud, this could result in physical or mental harm to a patient. Examples are if a provider performs a procedure or prescribes a drug that is unnecessary or dangerous.

Other examples of fraud include billing for:

  • A service that was never performed
  • A more expensive service, supply or piece of equipment than what was really provided
  • The same service twice (submitting more than one claim for the same service)

We all need to work together to reduce health care fraud. Blue Cross and Blue Shield of New Mexico works to fight fraud with help from our:

  • members
  • providers
  • employer groups
  • producers
  • local, state and federal agencies

Our Special Investigations Department (SID) is one of the best in the industry. The SID staff includes people with medical, insurance and law enforcement backgrounds. We also have data analysts who know how to detect fraud in billing schemes. The SID investigates reports of fraud. They also refer some cases for criminal prosecution.

How do I report fraud?

If you suspect fraud, there are ways to report it.

  • Report by Phone
    800-543-0867
    The toll-free Fraud Hotline is available 24 hours a day, 7 days a week. You can remain anonymous. Or you can let us know if you want to be contacted by the SID.
  • Report Online
    www.bcbsnm.com/sid/reporting
    This online fraud reporting form can be completed and sent to the SID.
  • Report by U.S. Mail
    Blue Cross and Blue Shield
    Special Investigations Department
    300 E. Randolph Street, 11th Floor
    Chicago, Illinois 60601

* Source: The Federal Bureau of Investigation (FBI), Financial Crimes Report to the Public for Fiscal Year 2011

 
 

Contact Us

If you have questions about Blue Cross Community Centennial, call 866-689-1523. Members with hearing or speech loss can call the TTY/TDD line at 711. You can also email us.