How to File an Appeal

You can appeal certain decisions or actions by BeWell. These include:

• Not eligible to buy a marketplace plan
• Not eligible for savings, like advance payments of the premium tax credit (APTC) or cost-sharing reductions (CSR)
• Eligible for APTC or CSR, but the amount is wrong
• Not eligible for a Special Enrollment Period
• A failure by BeWell to provide timely notice of an eligibility determination

BeWell can’t review the following issues:

• Your health plan company didn’t apply your premium tax credits correctly
• You believe your health plan owes you a refund
• You disagree with information on your Form 1095-A, or want a corrected form
• Your health plan refuses to pay a claim you think should be covered
• When you filed your federal income tax return, you owed back some or all of the premium tax credits you used during the year to lower your monthly premiums
• Medicaid eligibility

If you don’t agree with a decision made by BeWell, you generally have 90 days from the date of your eligibility notice to file an appeal.

In most instances, you can’t file an appeal until you receive your eligibility notice, which will state your eligibility for coverage, tax credits or cost sharing benefits. The eligibility notice will also describe your appeal rights.

You can file an appeal in any of the following ways:

Online

1. Login to your account at bewellnm.com
2. Click on the Benefits and Coverages menu at the top of the page.
3. Select Appeals.
4. Click on New Appeal and answer all questions. Make sure to click Save and Continue on each page and to click Submit when all information has been entered.

By Phone
Call our Customer Engagement Center at 1-833-ToBeWell (1-833-862-3935; TTY: 711) and a customer service representative will help you.

By Mail, Fax or In Person

1. Write out an appeal that includes all of the following information:
   • Account number, full name, date of birth and a valid phone number
   • Relevant plan year
   • Name of the household member(s) for whom you are appealing
   • The date of the notice containing the decision you are appealing
   • The decision you think is wrong and why you think it is wrong
   • If the appeal needs to be fast-tracked and why
   • Copies of any documents that support your appeal
   • Your signature
2. Mail or fax your appeal and copies of any documentation (keep a copy for your reference) to:
   New Mexico Health Insurance Exchange
   Appeals Department
   PO Box 25247
   Albuquerque, NM 87125Fax: 1-505-216-7776
3. Deliver your appeal and copies of any documentation in person to the BeWell administrative offices located at:
   7601 Jefferson St. NE, Suite 120
   Albuquerque, NM 87109
   Open Monday-Friday 8 a.m. – 4 p.m.

You can file a request for a faster (expedited) appeal if the time needed for the standard appeal process would jeopardize your life, health, or your ability to attain, maintain, or regain maximum function. (For example, if you’re currently in the hospital or urgently need medication.)

Your appeal request should explain why you need an expedited appeal. We’ll evaluate your request for an expedited appeal as quickly as possible and promptly notify you if your request is denied.

After you file an appeal, we will work with you to informally resolve your issue as quickly as possible. However, the appeal process may take up to 90 days.

Right to a fair hearing
Your right to a fair hearing is preserved in case you are not satisfied with the informal resolution of your appeal. If you request a hearing, the Human Services Department Office of Fair Hearings (OFH) will schedule and conduct the hearing. You will receive a letter with the time, place, and other details of the hearing. You will be able to present your case at the hearing. After the hearing, the OFH will send you a final written decision about your appeal.

Second-tier appeals to Health and Human Services
If you do not agree with the decision made by the OFH, you may file a second-tier appeal with the U.S. Department of Health and Human Services within 30 calendar days of the date of the OFH notice of appeal decision. Your OFH decision notice will tell you how to do this.

Note: You can ask for special accommodations for a disability or an interpreter be available during the informal resolution process. Accommodations are provided at no cost to you.

Yes. If you need help filing an appeal, you can make an appointment with a certified assister.

Can I Have an Authorized Representative Help Me with My Appeal?
Yes. You can have someone you trust (like a family member, friend, advocate, or attorney) act on your behalf for your appeal by giving them permission to be your authorized representative.
If you appoint an authorized representative, this person will be:

• The primary contact during your appeal
• Responsible for providing information and documents
• Responsible for returning phone calls, attending conferences, and any other actions for your appeal

Note: If you choose to have an authorized representative for your appeal, you will need to make sure you have an authorized representative designated in your BeWell account or that you have added this person on the paper appeal form. If you decide you no longer want your authorized representative to help with your appeal, you should contact the BeWell Appeals Department.

How Do I Make a Medicaid Appeal?
To appeal an issue related to Medicaid or the Children’s Health Insurance Program (CHIP), contact the New Mexico Human Service Department (HSD).

• By phone: 1-800-283-4465
• By text: 601-401-4995
• By email: NM.Customers@state.nm.us

You can find more information about Medicaid in New Mexico.

• Apply for Medicaid online.
• Get Medicaid assistance in your area.

How Do I Appeal a Carrier Decision?
Contact your insurance carrier if you need to appeal a decision or action by the carrier. Examples of issues you can appeal to your carrier include (but are not limited to):

• Your carrier denied a claim for a covered service or procedure
• A provider was listed as in-network, but didn’t accept your insurance
• You went to the emergency room and your bill says the provider was out-of-network

You can file a complaint with the Office of Superintendent of Insurance of New Mexico (OSI) if you are not satisfied with your carrier’s appeal decision, believe a carrier’s actions are discriminatory or unfair, or believe you have been fraudulently sold health insurance.

Employer Appeals
If you’re an employer who recently received notification that one of your employees was found eligible for a tax credit, you can appeal with the U.S. Department of Health and Human Services to prove that the coverage you offered your employee was both affordable and met the minimum value standard.