At BCSBNM, we take great pride in helping you get the care you need. If you receive an adverse benefit determination or have a complaint (a “grievance”) 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.
Adverse Benefit Determination
An adverse benefit determination is the denial, reduction, limited authorization, suspension, or termination of a newly requested benefit or benefit currently being provided to a member. These include determinations based on the type or level of service, medical necessity criteria or requirements, appropriateness of setting, or effectiveness of a service.
An appeal is a request for review of a benefit decision made by BCBSNM about a service. If you disagree with a benefit decision by BCBSNM, you may file an appeal. Disagreeing with a benefit decision by BCBSNM means you disagree with BCBSNM’s decision to terminate, modify, suspend, reduce, delay, or deny a benefit. You have up to 60 calendar days from the date of this letter to file an appeal. If you do not file an appeal within 60 calendar days from the date of this letter, you may lose your right to appeal. Call or write BCBSNM Member Services at 1-866-689-1523 (TTY: 711) to start your appeal.
A grievance is not the same as an appeal. A grievance is how you tell us that you are unhappy with us or our operation other than a benefit decision that we made. You can file a grievance even if you do not request an appeal. However, a grievance alone will not work to dispute a benefit decision. You must file an appeal to dispute a benefit decision. You can file both a grievance and an appeal at the same time. Call or write BCBSNM Member Services at 1-866-689-1523 (TTY: 711) to start your grievance. There is no time limit to start a grievance.
How to File an Appeal or Grievance
You may make a complaint or file an appeal by email, phone or in writing.
- Email: If you want to file an appeal, email BCBSNM at firstname.lastname@example.org.
- Call: If you want to file an appeal, call BCBSNM at 1-866-689-1523.
If you have a grievance about BCBSNM or a provider, call Customer Service at 1-866-689-1523. 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 660717
Dallas, TX 75266-0717
You must send us your written appeal within 13 calendar days after calling us or your appeal will be withdrawn. Please let us know if you need help filing your appeal in writing. If you or your provider believe that your health may be at risk if there is a delay, you do not need to send a written appeal. You can ask us to "expedite" your appeal (review it faster). A request for an expedited appeal may be made orally or in writing. See below for additional information about how to file an expedited appeal.
You or your appointed representative may use the Member Appeal Request Form and mail it to us at the address above.
You can also have your provider submit an appeal for you. Your provider can use the Provider Appeal Request Form. Please follow the instructions. Your provider will need to include certain information to support the request. Also, you must sign the form. Once completed, send it to the address shown on the form.
Time Limits for Filing
There are time limits for filing an appeal.
- Filing an Appeal – You may file an appeal by phone or in writing within 60 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 at any time.
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.
If you think the normal 30 calendar day appeal time will put your health at risk, you can ask us to “expedite” your appeal (review it faster). Your Centennial Care plan automatically provides an expedited review for all requests related to a continued hospital stay or other health care services for a member who has received emergency services and is still in the hospital. You or your provider can file an expedited appeal by calling Member Services. We will tell you within 1 working day if we agree to expedite your appeal. If we agree, we will tell you and/or your provider the outcome over the phone within 72 hours after we receive your appeal. We will send a follow-up letter within 2 calendar days telling you and your provider the outcome.
You or your authorized representative may ask for up to a 14-day extension to submit additional information to BCBSNM that supports your request for an expedited appeal.
If we need more time to answer your expedited appeal to collect and review additional information, we can extend the 72-hour time frame up to 14 calendar days. We will write you a letter to explain why we extended the 72-hour time frame.
If an expedited appeal request is denied, it goes through the normal appeal process. It will be resolved within 30 calendar days. BCBSNM will call you within 1 working day to tell you the appeal is not going to be expedited. We will also follow up in writing within 2 calendar days. If we deny your expedited request, you can request a standard or expedited Fair Hearing.
You have the right to ask for a hearing with the State Fair Hearings Bureau if after exhausting BCBSNM’s internal appeal process, you do not agree with the final decision. You or your representative must ask for a Fair Hearing from the State’s Fair Hearings Bureau within 90 calendar days of BCBSNM’s final appeal decision.
If you have any questions about Fair Hearings, call the Fair Hearings Bureau. You can call them at 1-800-432-6217, then press option 6, or at 505-476-6215.
This is just a brief description of appeals and grievances. For more details, see the Member Handbook.