Member Complaints and Appeals
NMHC takes member complaints, in the form of grievances and appeals, seriously. Complaints are an important mechanism for identifying concerns and dissatisfaction among our membership. Member 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).
Members have the right to file an appeal if they disagree with a NMHC decision to deny a service, in whole or in part. Members may also file a grievance related to our administrative practices, such as those decisions that appear to affect the availability, delivery or quality of health care services, including but not limited to claims payment or termination of coverage.
A complaint may be filed by a member or another person authorized to do so by the member. The member should initially contact the Customer Care Center at (855) 7MY-NMHC, or (855) 769-6642. A Customer Care Center representative will make every effort to resolve the member’s complaint to his or her satisfaction the first time it is brought to our attention. If the Customer Care Center representative is unable to resolve the concern or Complaint to the Member’s satisfaction, the Member can request that a formal appeal or grievance be filed.
If a member exhausts the appeal or grievance process, he/she has the right to request an external independent review by the New Mexico Office of Superintendent of Insurance.
For detailed information regarding member grievances and appeals, visit our Member Rights and Responsibilities page or contact us at 1-855-7MY-NMHC/1-855-769-6642.