Provider Grievances and Appeals
NMHC takes provider and practitioner complaints, in the form of grievances and appeals, seriously. Complaints are an important mechanism for identifying concerns and dissatisfaction within our provider network. Provider grievances and appeals are processed to ensure a timely and thorough investigation and according to federal and/or state regulatory requirements, as well as accreditation standards of the National Committee for Quality Assurance (NCQA).
Providers may file a grievance by:
Calling the Customer Care Center at 1-855-7MY-NMHC (1-855-769-6642)
Faxing us at 1-800-747-9132, ATTN: Appeals & Grievances
Writing to us:
New Mexico Health Connections
ATTN: Appeals & Grievances
P.O. Box 36719
Albuquerque, NM 87176
Provider Grievances Regarding NMHC’s Plan of Operation
Generally, provider grievances involving the operation of our plan fall into two categories: Appeals and grievances.
For appeals challenging a claim denial, claim adjudication, claim submission or claim resubmission not acted upon, providers must file this appeal within 180 days from the initial Explanation of Payment (EOP) denial. Grievances of this type must be submitted in writing, following claims processing and receipt of a formal denial from NMHC.
Please review the Reassessments/Adjustment Requests section of the Claims Submission and Payment section of this handbook to determine if non-payment requires a reassessment or adjustment request or filing a formal, written appeal.
Informal NMHC Review of Grievances
When verbal complaints or inquiries for non-payment issues are received by NMHC, they are initially forwarded to the NMHC Provider Services department. Provider Services’ staff researches the issue, takes action if appropriate, documents any action taken and responds to the provider, usually within three (3) business days. If resolution is not forthcoming via this informal review process, the provider is notified that they can file a formal written Provider Grievance.
Formal NMHC Review of Grievances
If NMHC is unable to resolve a verbal complaint or inquiry to the provider’s satisfaction, as described above, he/she may request, in writing, that the complaint be taken to the NMHC Provider Reconsideration Committee for review. This committee consists of NMHC management and/or other staff. A written decision of the NMHC Provider Reconsideration Committee will be sent to the provider within twenty (20) working days, following receipt of all necessary information needed to respond.
Review of Provider Grievances by the New Mexico Office of Superintendent of Insurance (OSI)
Following this internal review, if the provider remains dissatisfied with the result of the internal appeal and grievance process, he/she may file a complaint with the OSI. The provider must file a written request with the OSI within thirty (30) days from receipt of the written decision of the NMHC Provider Reconsideration Committee.
Please contact us at 1-855-7MY-NMHC (1-855-769-6642) for detailed information regarding our Provider Grievance program.
Appeal Process for Provider Terminations
Through a variety of sources, NMHC may discover that a practitioner is not meeting the standards of providing reliable, safe, quality care to his or her patients who are NMHC members. In these circumstances, there is a range of actions NMHC may pursue to ensure the provision of safe and effective care, including review of the practitioner’s current status with a variety of Boards or oversight bodies (e.g., the New Mexico Board of Medical Examiners), the implementation of a corrective action plan to address the documented performance deficiency, or even the removal of the practitioner from the network, the latter referred to as “termination for cause.” Providers should note that NMHC is required to notify appropriate authorities when it acts to limit, suspend, or terminate a practitioner’s participation in the network. NMHC does offer a practitioner the opportunity to appeal such adverse participation decisions.
For a variety of reasons, NMHC may end its contractual relationship with a provider solely based on business needs, referred to as “termination without cause.” Terminations without cause may include the periodic removal of a practitioner from the NMHC network when there are more practitioners than needed to meet NMHC’s accessibility and availability standards. Such terminations are not related to practitioner performance, quality of care or service, or a material breach of contract. Nor are terminations without cause subject to an appeal process.
For detailed information regarding our policy and procedures regarding provider terminations, please contact us at 1-855-7MY-NMHC (1-855-769-6642).