Blue Cross and Blue Shield of New Mexico

October 2016

Member Rights and Responsibilities

BCBSNM is committed to ensuring that enrolled members are treated in a manner that respects their rights as individuals entitled to receive health care services. BCBSNM is committed to cultural, linguistic and ethnic needs of our members. BCBSNM policies help address the issues of members participating in decision-making regarding their treatment; confidentiality of information; treatment of members with dignity, courtesy and a respect for privacy; and members’ responsibilities in the practitioner-patient relationship and the health care delivery process.

BCBSNM also holds forth certain expectations of members with respect to their relationship to the managed care organization and the independently contracted providers participating Blue Cross Community Centennial. These rights and responsibilities are reinforced in member and provider communications, including the provider website.

BCBSNM encourages all of our independently contracted providers to become familiar with the following member rights and responsibilities so that you can assist us in serving our members in a manner that is beneficial to everyone.

  1. Our members have a right to know their rights.
    • Members have the right to receive information about the rights and responsibilities.
    • Members have the right to make recommendations about these rights and responsibilities.
  2. Our members have the right to respect, dignity and privacy. That includes the right to:
    • Nondiscrimination.
    • Know that their medical records and discussions with their providers will be kept private and confidential.
    • Ask for and receive their medical records and if needed, have them corrected.
  3. Our members have the right to a fair opportunity to choose a health care plan and health care providers. They also have the right to change their plan or their provider without penalty at any time. That includes the right to:
    • Be told how to choose a health plan and Primary Care Physician (PCP) available in their area.
    • Be told how to change their health plan or their PCP.
    • Get information about providers and practitioners available to them.
  4. Our members have the right to ask questions and get answers about anything they do not understand. That includes the right to:
    • Have their provider explain their health care needs to them and talk to them about the different ways their health care problems can be treated, regardless of cost or benefit coverage.
    • Be told why care or services were denied and not given.
  5. Our members have the right to agree to or refuse treatment and have a say in treatment decisions. That includes the right to:
    • Work as part of a team with their provider in deciding what health care is best for them.
    • Say “yes” or “no” to the care recommended by their provider.

  6. Our members have the right to use each complaint and appeal process available through the Managed Care Organization and through Medicaid. That includes the right to:
    1. Make a complaint to their health plan or to the state Medicaid program about their health care, their provider or their health plan.
    2. Get a timely answer to their complaint.
    3. Use the Plan’s appeal process and be informed on how to file a complaint.
    4. Ask for a fair hearing from the State Medicaid program and get information about how that process works.
  7. Our members have the right to quick and easy access to care. That includes the right to:
    1. Have telephone access to a medical professional 24 hours a day/seven days a week for any emergency or urgent care they need.
    2. Receive medical care in a timely manner.
    3. Get in and out of a health care provider’s office easily. There should not be any conditions that limit movement for people with disabilities according to the Americans with Disabilities Act.
    4. Have interpreters, if needed, when getting covered services during appointments with their providers and when talking to their health plan. Interpreters are people who can speak their native language, help someone with a disability, or help them understand the information.
    5. Be given information they can understand about their health plan rules, the services they can get and how to get them.
  8. Our members have the right to refuse to be restrained or secluded for someone else’s convenience or as a way of forcing them to do something they do not want to do, or as punishment.
  9. Our members have the right to have open discussions with their doctors, hospitals and others who care for them regarding their health status, medical care and all options for treatment, even if the care or treatment is not a covered service.
  10. Our members have the right to know that they are not responsible for paying for covered services in accordance with the terms in their evidence of coverage.


Our members have the responsibility to:

1. Read and follow the Member Handbook.

2. Keep their scheduled appointments or call their provider to reschedule or cancel at least 24 hours before their appointment.

3. Show their Blue Cross Community Centennial ID card to each provider before getting covered services.

4. Call their PCP or the 24/7 Nurseline before going to an emergency room, except in situations that they believe are life threatening or that could permanently damage their health.

5. Follow plans and instructions for care that they have agreed to with their providers.

6. Call Member Services if they change their phone number or their address. They should also contact their Case Worker at the Human Services Department (HSD).

7. Share information about their health with their PCP and learn about service and treatment options. That includes the responsibility to:

  1. Tell their PCP about their health.
  2. Talk to their providers about their health care needs and ask questions about the different ways their health problems can be treated.
  3. Help their providers get their medical records.
  4. Treat their providers and other health care employees with respect and courtesy.

8. Be involved in service and treatment option decisions, and make personal choices to help keep themselves healthy. That includes the responsibility to:

  1. Work as a team with their provider in deciding what health care is best for them.
  2. Understand how the things they do can affect their health.
  3. Do the best they can to stay healthy.
  4. Treat providers and staff with respect.
  5. Talk to their provider about all of their medications.

If our members think they have been treated unfairly or discriminated against, they can call the U.S. Department of Health and Human Services (HHS) toll-free at 800-368-1019. They can also view information concerning the HHS Office for Civil Rights online at




Blue Review • October 2016

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association.

P.O.Box 27630, Albuquerque, NM 87125-7630