If you don’t agree with a decision made by beWellnm, you may be able to file an appeal.

What issues can I appeal?

 You can appeal certain decisions or actions by beWellnm. 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 beWellnm to provide timely notice of an eligibility determination.

*You can also appeal a decision that you are not eligible for a Catastrophic health plan. However, Catastrophic plans will be offered through beWellnm for plan year 2023.

BeWellnm 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.

How much time do I have to file an appeal?

In most instances, you can’t file an appeal until you get an eligibility notice from beWellnm that says your eligibility for coverage or tax credits and cost sharing benefits was denied, has ended or your savings have changed. The eligibility notice will also describe your appeal rights.

You generally have 90 days from the date of your eligibility notice to file an appeal.

How do I file an appeal?

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 on Save and Continue on each page and 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. Complete our paper appeal form or 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 87125
Fax: 1-505-216-7776

3. Deliver your appeal and copies of any documentation in person: beWellnm, 7601 Jefferson St. NE, Suite 120, Albuquerque, NM 87109 (Note:  Office hours may be limited due to COVID restrictions.  Please call or visit our website for updated information).

Can my appeal be fast-tracked?

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.

What happens after I file an appeal?

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.

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 HHS

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.

* You can ask for special accommodations for a disability or that a language or speech interpreter be available during the informal resolution process. Accommodations are provided at no cost to you.

Can someone help me file my appeal?

Yes. If you need help filing an appeal, click here to be connected to a broker or 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 beWellnm 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 beWellnm Appeals Department.

Medicaid Appeals

To appeal an issue related to Medicaid or the Children’s Health Insurance Program (CHIP), contact the New Mexico Human Service Department (HSD). HSD administers Medicaid and can support you with issues or questions about eligibility and enrollment. (This does not apply to small business owners wishing to participate in the beWellnm Small Business Health Options Program (SHOP)).

You can contact the Human Services Department in any of the following ways:

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

Click here for the online Medicaid application.
Click here for more information about Medicaid in New Mexico.
Click here for assistance in your local area.

Appeals of Carrier Decisions

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 of 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.

How do I file a Small Business Health Options (SHOP) appeal?

Employers participating in our Small Business Health Options Program (SHOP) can appeal the following issues:

• Denial of SHOP eligibility
• SHOP not making an eligibility determination in a timely manner
• A failure by beWellnm to provide timely notice of an eligibility determination.

Write or type an appeal using the guidance above and provide using a secure email for data security purposes to Appeals@nmhix.com.

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. To file an appeal form, click here.