Blue Cross and Blue Shield of New Mexico (BCBSNM) is pleased to offer resources to help you better manage your health care. We welcome your input. We also respect your rights as a member and want you to be aware of those rights. If you were not able to make decisions about your own health care, who would you want to handle this for you? Take some time to check out resources to help with these and other topics.
The Member Advisory Board (MAB) plays a key role in helping BCBSNM improve the Blue Cross Community Centennial health plan. We want to know your experience with services you receive for behavioral health, physical health, long-term care and more. This board can include Blue Cross Community Centennial members and their family. It can also include health care providers.
MAB meetings occur each quarter (4 times a year) in Albuquerque. There are also 2 statewide meetings each year. Please see the schedule for upcoming MAB meetings . There may be an option to call in to the meeting if you cannot attend in person.
To learn more about MAB or to make a reservation, please contact Christine Rocha. Call (505) 816-4316 or email firstname.lastname@example.org.
Native American Advisory Board
The Native American Advisory Board (NAAB) is a team like the MAB. But NAAB is a team that can advise BCBSNM on issues related to Native Americans. This can include issues with the health plan or services you receive. NAAB may also discuss provider-related topics such as claims processing and reimbursement issues.
NAAB meetings are held each quarter (4 times a year). This board may include appointed tribal representatives, Native American plan members and providers. Please see the schedule for upcoming NAAB meetings . There may be an option to call in to the meeting if you cannot attend in person.
To learn more about NAAB or to make a reservation, please contact Bonnie Vallo. Call (505) 816-2210 or email email@example.com.
As a Blue Cross Community Centennial member, you have the right to:
- Be treated with respect
- Have your dignity and privacy recognized
- Receive health care that is free from discrimination
- Be given information about BCBSNM products, services, providers, and how to access care
- Choose a primary care physician (PCP) from BCBSNM's network of doctors
- Get information about your treatment options in clear language that you understand
- Request a second opinion
- Get emergency care when and where you need it, without prior approval
- Decide on advance directives for your health care
- File complaints and receive a response in a reasonable amount of time
As a member of Blue Cross Community Centennial, you have the following responsibilities:
- Give complete health information to help your doctor give you the care you need
- Follow treatment instructions for drugs, diet and exercise as agreed upon by you and your doctor
- Take part in coming up with treatment goals with your doctor
- Make appointments ahead of time for doctor visits
- Keep your appointment – or call at least 24 hours before if you need to reschedule or cancel
- Know the name of your PCP and have your PCP provide or arrange your care
- Tell your doctor if you do not understand how your health care is explained
- Treat your doctor and other health care employees with respect and courtesy
- Show your ID card before getting health care services (or you may be billed for the service)
- Give a copy of your living will and advance directives to your PCP to put in your medical records
- Provide NM Human Services Department and BCBSNM with your current:
- Mailing address
- Phone number
- Emergency contact information
- Email address (if you have email)
For a complete list of member rights and responsibilities, see the Member Handbook .
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 . Download a POA/Advance Health Care Directives form with instructions .
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.
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.
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.
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.
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 .
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.
- 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:
- employer groups
- 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
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
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