Understanding Fraud, Waste, and Abuse
Health insurance fraud, waste, and abuse has a negative impact on all of us. At True Health New Mexico, we seek to prevent, detect, and investigate all forms of fraud, waste, and abuse. We are required to cooperate with and report any suspicious activity to the appropriate law enforcement and regulatory authorities.
Protect Yourself From Fraud, Waste, and Abuse
- Do not give your plan identification (ID) number over the telephone or to people you do not know, except to your health care provider or OPM representative.
- Let only the appropriate medical professionals review your medical record or recommend services.
- Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to have it paid.
- Carefully review explanations of benefits (EOBs) you receive from us.
- Periodically review your claims history for accuracy to ensure we have not been billed for services that you did not receive.
- Do not ask your doctor to make false entries on certificates, bills, or records in order to get us to pay for an item or service.
What Should You Do if You Suspect Fraud, Waste, or Abuse?
If you suspect a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
- Call the provider for an explanation. There may be an error.
- If the provider does not resolve the matter, call our Fraud, Waste, and Abuse Hotline at 1-855-882-3903 and explain the situation.
For more information, please refer to your plan’s Evidence of Coverage (member handbook). If you are a Federal Employees Health Benefits Program member, please refer to your FEHB Brochure.
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.