Member Rights and Responsibilities

As a Member of this Plan, you are entitled to certain rights when you access coverage. There are also certain responsibilities that you hold. It is important that you understand these rights and responsibilities.

Health Plan Member Rights

  • You have a right to detailed information about your Plan. This may include benefits and services that are covered or excluded from the Plan, and all requirements that must be followed for Prior approval and Utilization Review.
  • You have a right to always have available and accessible services for Medically Necessary and covered services; including 24 hours per day, 7 days per week for urgent and emergency care services, and for other healthcare services as defined by the Evidence of Coverage or the Summary of Benefits and Coverage.
  • You have a right to information about your out-of-pocket expense limitations, and an explanation of your financial responsibility for services provided to you.
  • You have a right to be treated in a manner that respects your privacy and dignity.
  • You have a right to participate with your Providers in making decisions about your healthcare.
  • You have a right to receive an explanation of your medical Condition; recommended treatment; risks of the treatment; expected results; and reasonable medical alternatives from your Provider in a language that you understand, regardless of cost or your plan’s benefits.
  • You have a right to be informed about your treatment from your Participating Provider; to request your consent (agreement) to the treatment; to refuse treatment, including medication; and to be told of the possible consequences of refusing such treatment. This right exists even if treatment is not a covered benefit or Medically Necessary according to the Plan. The right to consent or agree to treatment may not be possible in a medical emergency where your life and health are in serious danger.
  • You have a right to voice Complaints, Grievances or Appeals with the Plan or its regulatory bodies about the Plan and/or the care that we provide.
  • You have a right to make recommendations regarding the Plan’s Member Rights and Responsibilities policies.
  • You have a right to receive assistance in a prompt, courteous and responsible manner.
  • You have a right to the confidential handling of all communication and information maintained by the Plan. Your written permission will always be required for the release of medical and financial information, except:
    • When clinical data is needed by healthcare Providers for your care;
    • When the Plan is bound by law to release information;
    • When the Plan prepares and releases data but without identifying Members; and
    • When necessary to support the Plan’s programs or operations, including for payment and to evaluate quality and service.
  • You have a right to be promptly informed of termination or changes in benefits, services or Participating Providers.
  • You have a right to know, upon request, of any financial arrangements or provisions between the Plan and its Participating Providers, which may restrict referrals or treatment options or limit the services offered to you.
  • You have a right to receive an explanation of why a benefit is denied; the opportunity to appeal the denial decision; the right to a second level of appeal with the Plan; and the right to request help from the New Mexico Superintendent of Insurance.
  • You have a right to adequate access to healthcare providers near your home or work within the Plan’s service area.
  • You have a right to receive detailed information about requirements that you must follow for prior approval of certain services.
  • You have a right to have access to a current list of Participating Providers in the Plan’s network.
  • You have the right to an example of the financial responsibility incurred by a Covered Person for services received from an Out-of-Network or Non-Participating Provider.

You are responsible for learning how your Plan works. You should carefully read and refer to your Evidence of Coverage (also called a Member Handbook) and your Summary of Benefits and Coverage. Contact the Customer Care Center if you have questions or concerns about your Plan.

Health Plan Member Responsibilities

  • You have a responsibility to provide honest and complete information to the Plan and to your Providers.
  • You have a responsibility to read and understand the information that you receive about your Plan.
  • You have a responsibility to know how to properly access coverage and utilize your Plan.
  • You have a responsibility to understand your health problems and participate in developing treatment goals that you agree to with your Providers.
  • You have a responsibility to follow plans and instructions for care that you have agreed to with your Providers.
  • You have a responsibility to present your Plan ID card before you receive care.
  • You have a responsibility to promptly notify your Provider if you will be delayed or unable to keep an appointment.
  • You have a responsibility to pay your applicable Deductible, Copayment and Coinsurance amounts, including those for missed appointments.
  • You have a responsibility to express your opinions, Concerns or Complaints in a constructive way to the Plan or to your Provider.
  • You have a responsibility to inform the Plan and/or your Employer of any changes in family size, address, phone number or Membership status within thirty (30) calendar days of the change.
  • You have a responsibility to make Premium payments on time if they are not paid directly by your Employer.
  • You have a responsibility to notify the Plan if you have any other insurance coverage.
  • You have a responsibility to follow the Plan’s Complaints and Appeals process when you are dissatisfied with the Plan or a Providers’ actions or decisions.

Adverse Determinations and Your Appeal Rights

An adverse determination happens when True Health New Mexico reviews a healthcare service a member has received and decides that it was not medically necessary. If you receive a notice of an adverse determination from True Health New Mexico and are not satisfied, you can ask for an external review at no extra cost.

The Office of the Superintendent of Insurance (OSI) conducts external reviews. The OSI is not connected in any way to True Health New Mexico. Once the OSI has made its decision, True Health New Mexico must carry out its instructions. The OSI may require members to go through the True Health New Mexico internal appeal process before asking for an external review. However, if your situation meets the definition of “urgent” under the law, you or your provider may ask for an expedited (urgent) external, independent OSI review at the same time that you file an internal urgent appeal.

How to Request an External Eeview

You may mail, email, or fax your request for an external, independent review to the OSI. You must file your request within 120 calendar days that you receive True Health New Mexico’s written notice of adverse determination.

  • By mail:
    New Mexico Office of Superintendent of Insurance
    Attn: Managed Health Care Bureau – External Review Request
    P.O. Box 1269, 1120 Paseo de Peralta
    Santa Fe, NM 87504-1269
  • By email: mhcb.grievance@state.nm.us. Put “External Review Request” in the subject line.
  • By fax: (505) 827-4734. Write “Managed Health Care Bureau – External Review Request” on the cover sheet.​

Questions about Your External Appeal Rights?

Contact the Managed Health Care Bureau of the OSI by calling (505) 827-4734 or writing or emailing the OSI (see above). You also may call True Health New Mexico with questions about your appeal rights or the appeal process at 1-844-508-4677.