Member Information
Navigate Coverage Decisions For Your Medical Care
Learn about how coverage decisions are made, such as asking for prior authorization and your right to file an appeal or grievance.
Medical Prior Authorizations, Appeals and Grievances
You have the right to ask us to pay for an item or service you think should be covered. Coverage decisions are about your benefits and the amount we pay for your health care or drugs. As your insurance plan, we want you to know your rights and options. This process works in steps and Blue Cross and Blue Shield of New Mexico is committed to helping you through each step.
Step 1: Ask For a Prior Authorization
Your first step may be to ask for a Prior Authorization. Some health services need approval, called Prior Authorization, from BCBSNM before you get care. If a service isn't approved, it won't be covered by BCBSNM.
Most often, your health care providers handle this before treatment. However, it is always a good idea to check. You and your provider can still decide to go ahead with the service, but you may have to pay if it is not approved. Your doctor or an office staff member may ask for a medical prior authorization by phone, fax, or mail.
Please visit our Contact Us page for more information.
Step 2: File an Appeal
If coverage for an item or medical care is denied and you think it should be covered, you can file an appeal. An appeal is a formal request asking us to review and changer a coverage decision we made.
You will get a written response to your appeal as quickly as your case requires. The response will be:
- No later than 30 calendar days after we receive your appeal for medical service authorization; or
- No later than 60 calendar days after we receive your appeal for payment.
We may add to the time frame by up to 14 calendar days if you ask for an extension.
You may file a medical appeal by fax or mail. Please visit our Contact Us page for more information.
Step 3: File a Grievance
You, or an appointed representative, can file a grievance if you have a complaint about what is covered for medical services, the quality of care you receive, the timeliness of service or any other concern (except for the coverage or payment issues listed above).
You can file a grievance by phone, fax or mail. To file a grievance, please visit our Contact Us page.
Important: You must file a grievance with us no later than 60 days after the event or incident in question.