July 2017  

Member Rights and Responsibilities

BCBSNM members have the right to:

• Available and accessible services when medically necessary, as determined by the primary care or treating physician in consultation with BCBSNM, 24 hours per day, 7 days a week, or urgent or emergency care services, and for other health services as defined by the member’s benefit booklet.
• Be treated with courtesy and consideration, and with respect for their dignity and need for privacy.
• Have their privacy respected, including the privacy of medical and financial records maintained by BCBSNM and its health care providers as required by law.
• Be provided with information concerning BCBSNM’s policies and procedures regarding products, services, providers, appeals procedures and other information about the company and the benefits provided.
• All the rights afforded by law, rule, or regulation as a patient in a licensed health care facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language they understand.
• Receive from their physicians or providers, in terms that they understand, an explanation of their complete medical condition, recommended treatment, risks of the treatment, expected results and reasonable medical alternatives, irrespective of BCBSNM’s position on treatment options. If they are not capable of understanding the information, the explanation shall be provided to their next of kin, guardian, agent or surrogate, if able, and documented in their medical record.
• Prompt notification of termination or changes in benefits, services or provider network.
• File a complaint or appeal with BCBSNM or with the New Mexico Superintendent of Insurance and to receive an answer to those complaints within a reasonable time.
• Request information about any financial arrangements or provisions between BCBSNM and its network providers that may restrict referral or treatment options or limit the services offered to members.
• Adequate access to qualified health professionals near their work or home within New Mexico.
• Affordable health care, with limits on out-of-pocket expenses, including the right to seek care from an out-of-network provider, and an explanation of their financial responsibility when services are provided by an out-of-network provider, or provided without required preauthorization.
• Detailed information about coverage, maximum benefits, and exclusions of specific conditions, ailments or disorders, including restricted prescription benefits, and all requirements that they must follow for preauthorization and utilization review.
• Make recommendations regarding BCBSNM’s member rights and responsibilities policies.
• A complete explanation of why care is denied, an opportunity to appeal the decision to BCBSNM’s internal review, the right to a secondary appeal, and the right to request the assistance of the Superintendent of Insurance. BCBSNM members have the responsibilities to:
• Supply information (to the extent possible) that BCBSNM and its network practitioners and health care providers need in order to provide care.
• Follow plans and instructions for care that have been agreed on with their treating provider or practitioners.
• Understand their health problems and participate in developing mutually agreed upon treatment goals with their treating provider or practitioner to the degree possible.