Complaint Form
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2STATE OF NEW MEXICO
OFFICE OF SUPERINTENDENT OF INSURANCE
P.O. Box 1689
SUPERINTENDENT OF INSURANCE
John G. Franchini - (505) 827-4299
Santa Fe, NM 87504-1689
1120 Paseo de Peralta, Room 428
DEPUTY SUPERINTENDENT
Santa Fe, NM 87501
Alan Seeley – (505) 827-4307
MANAGED HEALTH CARE BUREAU
1-855-427-5674
505-827-4601
COMPLAINT FORM
The Managed Health Care Bureau will investigate this complaint to determine if there are any violations of the New Mexico
Insurance Code, Managed Health Care Rule or insurance policy language.
Name______________________________________ Mailing Address___________________________________
City_______________________________ State____________________ Zip__________
Telephone (home) ___________________ (work) ______________ (other) ________________
Type of Complaint
(Please circle)
Member Provider Other
ID #______________________GROUP # _______________________ Name of Employer: ______________________
Type of Health Care Plan?
Individual
Group
Medicaid
Self-funded
Medicare Supplement Plan
The NM School Authority
PPO
The NM Retiree Authority
Other: ___________________
Not sure
Name of Insurance Company
Lovelace
Presbyterian
BCBS of New Mexico
Amerigroup New Mexico, Inc.
Molina
Other: ____________________________
DOES THIS COMPLAINT CONCERN?
Payment of fees
Referral/Prior Authorization
Treatment
Emergency Room
Physicians Issue
Administrative Issue
Other ______________________________
Have you started the appeal process? Yes
No
If yes, at what level is your complaint in the internal health plans process?
Medical Director
Internal Panel Review
Exhausted Internal Review; Requesting an External Review Request
PLEASE ATTACH A COPY OF YOUR BENEFITS BOOKLET
(Please turn page over)
PLEASE SUMMARIZE YOUR COMPLAINT. (ATTACH COPIES OF ANY DOCUMENTS THAT MIGHT BE
RELATIVE TO YOUR COMPLAINT.)
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