Appeals and Grievances

Understanding Appeals, Grievances and Benefit Decisions

Check the Member Handbook to learn more about appeals and grievances.

When to File Appeal or Grievance

There are time limits to file an appeal.

• Filing an Appeal – You may file an appeal within 60 calendar days of a denial letter from BCBSNM. 
• Filing a Grievance – You may file a grievance at any time. There is no time limit to file a grievance.

We will confirm that we received your request within 5 business days. 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 New Mexico HCA for more time to explain or research the issue. You or your authorized representative may ask for up to a 14-day extension to submit more information to BCBSNM that supports your request for an expedited appeal.

How to File an Appeal or Grievance

There are different ways to file an appeal or grievance. Check the options below.

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.

Please let us know if you need help filing your appeal. If you or your provider believe that taking the time for a standard appeal puts your health at serious risk, you can ask us to "expedite" your appeal (review it faster). Check below to learn more about how to file an expedited appeal.

How to Appeal a Pharmacy Service

If you would like to appeal a pharmacy service, you or your provider can:

Expedited Appeals

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 Turquoise Care plan automatically provides an expedited review for a continued hospital stay and 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. If we agree to expedite your appeal, 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 that tells you the outcome. Sometimes we may need more time to collect and review additional information so we can answer your appeal. If so, 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. Also, if we deny your expedited request, you can request a standard Fair Hearing. 

What Happens After an Appeal Is Filed?

After you file an appeal, we will let you know we received it. We’ll also let you know when we expect to have an answer for you. BCBSNM will review your request and then send a letter to let you know the decision. The letter will be sent to you and/or your authorized representative.

Fair Hearing

If you are not happy with the results of your appeal, you have the right to ask for a hearing with the HCA Office of Fair Hearings. This must be done after exhausting BCBSNM’s internal appeal process, if you do not agree with the final decision. You may have a representative act on your behalf. 

If you have any questions about Fair Hearings, contact the Office of Fair Hearings.

You or your representative must ask for a hearing from the Office of Fair Hearings:

• Within 90 calendar days of BCBSNM’s final appeal decision for a standard request.
• Within 30 calendar days of BCBSNM’s final appeal decision for an expedited request.