Seeking Healthcare Services

The Right Care at the Right Time

At True Health New Mexico, we encourage members to seek healthcare services to ensure you and your family are up-to-date on preventive screenings. We understand it can be difficult and overwhelming to navigate the ever-changing healthcare system. We are here to help and make it easy for you!

Explore this page to help you decide which type of provider you should see, where you should go, and when.

Choosing the Right Doctor

How to know whether you should see your primary care provider vs. a specialist.

Care Connect Line / Nurse Advice Line

Expert guidance for your medical concerns, 24 hours a day, 7 days a week.

Understanding Urgent vs. Emergency Care

Knowing the difference can save you a lot of time and out-of-pocket costs. 

Pharmacy Benefits and Programs

View our drug lists, learn about pharmacy programs to support your health, and more.

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 True Health New Mexico HMO plan, you must choose a PCP who is in the True Health New Mexico network. If you enroll in a PPO plan, you may choose a PCP who is either in-network or out-of-network. However, you will have lower out-of-pocket costs if you choose an in-network PCP.

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. They can go to our Contracting with Us page to learn more and to contact us. But in the meantime, you’ll need to find a new PCP.

Search our online directory of providers. After you have found a PCP, call their office and ask if 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 Customer Service toll-free at 1-844-508-4677, 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. However, 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 True Health New Mexico plan does not require you to have a referral to see a specialist.

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 True Health New Mexico 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 True Health New Mexico include:

  • Applied behavioral analysis therapy
  • Electroconvulsive therapy
  • Partial hospitalization
  • Inpatient hospital admissions

True Health New Mexico offers a $0 copay for all outpatient behavioral health visits, including substance abuse treatment, for most plans.

To learn more, visit our Behavioral Health page.

Urgent Care
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 our provider network or dial 911.

Search for an in-network ER with our Online Provider Search Tool (visit “Find a Doctor” above). Staying in-network whenever possible helps us keep our overall operating costs down, which benefits all members.

Please note that:

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

Prior Authorization

Some services require approval (also called prior authorization) from True Health New Mexico 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 True Health New Mexico covers a treatment or service by:

  • Reviewing your Evidence of Coverage Handbook
  • Reviewing your Summary of Benefits and Coverage
  • Calling Customer Service at 1-844-508-4677.

When a provider in the True Health New Mexico network says you should have care that needs prior authorization, the provider must contact True Health New Mexico for approval. Our Medical Management team will review the request using nationally recognized guidelines. True Health New Mexico 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

Please read our statement regarding utilization review decisions.

Our Utilization Management Procedures

Utilization management (UM), sometimes called utilization review, is the evaluation of the medical necessity, appropriateness, and efficiency of the use of healthcare services, procedures, and facilities under the provisions of your health plan.

  • Most routine services, such as a visit with a PCP or specialist, do not need a prior authorization (PA). You usually need a PA for certain procedures or surgeries, exceptions to the formulary (drug list), and requests for services outside of our provider network.
  • When you do need a PA, your provider makes the request for you. The PA process can take place before the service occurs in planned and non-urgent situations, at the time of an urgent situation, and after receiving care. 
  • If you are admitted to a hospital, the facility must tell True Health New Mexico. It is up to you and your provider to see that all PA procedures outlined by True Health New Mexico are followed correctly. These procedures are in your Evidence of Coverage/Member Handbook.
  • When a PA is required, True Health New Mexico uses doctors who are licensed in New Mexico to conduct the reviews and to make determinations (decisions).
  • True Health New Mexico nurses review all inpatient services as they occur to ensure that you are receiving the best service for your level of care.
  • We offer case management services to True Health New Mexico members who have complex healthcare needs. This ensures that you receive appropriate and timely care.
  • We also offer transition-of-care services for up to 30 days. These services are for when you are being treated by a non-contracted provider at the time of your True Health New Mexico enrollment.
  • Find complete utilization management information in your Evidence of Coverage/Member Handbook.
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.

Pediatric Vision Services

Children under age 19 who are enrolled in Individual, Small Group, or Federal Employee Health Benefit plans are eligible for pediatric vision services.

They can receive an eye exam from a Vision Service Plan (VSP) provider one time per year. See your Evidence of Coverage (Member Handbook) for plan specifics.

They may also receive eyeglasses or contact lenses.

View a list of VSP providers on our Quick-Search PDFs page or visit VSP’s website at www.vsp.com.