Seeking Healthcare Services

Find a 2020 Provider

Find a 2019 Provider

Primary Care Providers (PCPs)

PCPs are physicians, nurse practitioners, and physician assistants who manage your overall healthcare needs. They provide services such as annual exams, routine immunizations (vaccines), and treatment for illnesses and injuries. PCPs include family practice doctors, general practitioners, internists, and pediatricians.

Finding and developing a relationship with a PCP will help you and your family navigate your health plan. It also can help you stay well and avoid costly future medical expenses.

Selecting a PCP

When you enroll in your NMHC HMO plan, you must choose a PCP who is in the NMHC network. If you already have a PCP, call his or her office to ask if that PCP is in our network. If the PCP isn't, you can ask them to consider becoming a contracted provider. But in the meantime, you'll need to find a new PCP.

Search our 2020 online directory of providers. You can browse the provider directory by provider name or specialty (internal medicine, general medicine, family practice, etc.) using the Online Provider Search Tool. After you have found a PCP, call their office and confirm they are accepting new patients—even if the directory says they are.

Before the PCP considers you a patient, you'll need to make an appointment for a first visit. If you have any recent lab work or test results, bring those to your appointment. Also make a list of any questions or concerns you may have.

You may change your PCP at any time by calling (866) 668-9002, Monday through Friday, 8 a.m. to 5 p.m., Mountain Standard Time.

Note: After you choose a PCP, you are free to see any other PCP within our network. But please keep in mind that it's important to establish yourself with one PCP. That provider will know you and have all of your medical history.

Specialty Care Providers (Specialists)

Specialists treat specific diseases, medical conditions, or parts of the body. Some examples of specialists include cardiologists (heart), orthopedists (bones and joints), neurologists (brain and nervous system), and endocrinologists (hormones, diabetes).

Your NMHC plan does not require you to have a referral to see a specialist.

Pediatric Vision Services

Children under age 19 who are enrolled in individual plans are eligible for pediatric vision services. They can receive an eye exam from a Vision Service Plan (VSP) provider once per year. Depending on your coverage, they may also receive eyeglasses or contact lenses. Please refer to your plan's Summary of Benefits and Coverage for details.

View a list of VSP pediatric vision service providers or visit VSP's website at www.vsp.com.
View a summary of benefits for pediatric vision services (for all plans except HDHP).
View a summary of benefits for pediatric vision services (for HDHP plans only).

After-Hours Care

If you call your provider after normal office hours, either an answering machine or an answering service should be available. For urgent problems, your provider’s answering service should offer to contact your provider or a doctor covering for him or her. If your provider’s office uses an answering machine, it should provide a phone number for the covering physician.

View the urgent care flyer

Emergency Care

Emergency rooms are equipped to handle the most serious and life-threatening health problems. They are open 24 hours a day, 7 days a week. If you have an emergency, go to the nearest emergency room in the NMHC network or dial 911.

Please note that:

In the Albuquerque and Rio Rancho areas, all Presbyterian clinics and hospitals, including ERs, are out of our network.
Whenever possible, if you need emergency care, please go to one of the following ERs.
- One of the three Lovelace hospitals in our network. If you have a non-life-threatening emergency, you will experience shorter wait times at one of these hospitals.
  1. Lovelace Medical Center, 601 Dr. Martin Luther King, Jr. Ave NE, Albuquerque, 87102
  2. Lovelace Westside Hospital, 10501 Golf Course Rd. NW, Albuquerque, 87114
  3. Lovelace Women's Hospital, 4701 Montgomery Blvd. NE, Albuquerque, 87109
- The Heart Hospital of New Mexico, 504 Elm St. NE, Albuquerque, 87102, if you have a heart emergency.
- UNM Hospital, 2211 Lomas Blvd. NE, Albuquerque, 87106, has the only Level I trauma center in the state. It gets very busy and crowded there, and patients who are not in life-threatening situations could wait a long time.

When you arrive at the emergency room, tell the staff that you are a NMHC plan member and show them your NMHC ID card. They can then call us for you. If the ER staff or you cannot call NMHC right away, please do so as soon as you can. We will provide direction as needed.

Behavioral (Mental) Health Services

You can find a behavioral health provider by searching our online provider directory. You do not need a referral or a prior approval from NMHC before seeking outpatient behavioral health services. Examples of these services include visits to a therapist, psychiatrist, or family counselor. Services that do need prior approval from NMHC include:

Applied behavioral analysis therapy
Electroconvulsive therapy
Partial hospitalization
Inpatient hospital admissions

NMHC offers a $0 copay for all outpatient behavioral health visits, including substance abuse treatment, for all plans except for our HDHP and catastrophic plans.

Prior Authorization

Some services require approval (also called prior authorization) from NMHC before you can receive care. The first step in the prior authorization process is to confirm whether a treatment or service is covered by your plan. If the service is not a covered benefit, the prior authorization process will not change this. You can confirm whether NMHC covers a treatment or service by reviewing your Evidence of Coverage Handbook and your Summary of Benefits and Coverage. You also can call Customer Service at (866) 668-9002. We can answer prior authorization questions that you or your provider may have.

When a provider in the NMHC network says you should have care that needs prior authorization, the provider must contact NMHC for approval. Our Medical Management team will review the request using nationally recognized guidelines. NMHC and practicing healthcare providers have developed these guidelines. They are consistent with sound clinical principles. If guidelines do not exist for a certain service or treatment, then we use resource tools based on clinical evidence. Examples of services that require prior authorization are:

Non-emergency inpatient hospital admissions
Non-emergency surgeries
Imaging procedures such as MRI, CT scans, and PET scans
Durable medical equipment (DME) and prosthetics

Outpatient Prescription Drugs

NMHC uses a Pharmacy Benefits Administrator (PBM) to administer prescription drug benefits. OptumRx is your plan’s PBM. You can contact OptumRx at 1-855-577-6550 or OptumRx.com. NMHC requires you to use a pharmacy in the OptumRx network or OptumRx mail-order program. OptumRx's network includes local retail pharmacies throughout New Mexico and the U.S. and a specialty pharmacy called Briova.

NMHC provides coverage for drugs, supplies, supplements, and administration of a drug (if such services would not otherwise be excluded from coverage). The drugs must be prescribed by a licensed and qualified provider. NMHC offers a $0 copay for most generic drugs for chronic conditions such as asthma, diabetes, and depression, on all plans except for our HDHP and catastrophic plans.

NMHC uses a preferred drug list (formulary). This is a list of prescription drugs that we cover. The formulary includes drugs for a variety of diseases and conditions. If you have questions about our formulary or your outpatient prescription drug benefits, call Customer Service at 1-866-668-9002. You also can view the formulary on our website at www.mynmhc.org/Formulary.aspx. You’ll find more information about prescription drug limitations and exclusions in the Exclusions section of your Evidence of Coverage Handbook.

Are you looking for health insurance?