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Appeals, Grievances & Exception Process

We are committed to providing you with high-quality care and service. If you’re not satisfied, we want to know. There are a few types of complaints you can file if you are not satisfied with the coverage of your services or with your care.

View Medicare Appeals, Grievances and Exception information

Appeal

An Appeal is the type of complaint you make when you want us to reconsider and change a decision we have made about what services are covered for you or what we will pay for.

A Fast (Expedited) Appeal may be requested only when it is an emergency medical issue. This type of appeal is for those cases in which a longer time to reach a decision may increase the medical risk to the Member. This does not apply to issues such as the request to change a decision regarding how a claim was paid. Your appeal request may be submitted in writing or may be submitted verbally by calling the Presbyterian Customer Service Center (PCSC) at 1-800-356-2219 or TTY users should call 711. Fast Appeal Requests may also be submitted by calling PCSC at 505-923-5678 or toll free at 1-800-356-2219 or TTY users should call 711, Monday through Sunday 7 a.m. to 6 p.m. Fast appeals may also be faxed to 505-923-5124.

How to file an Appeal

You may call PCSC to start the appeal process or you may send a letter to the Appeals Coordinator. Presbyterian must receive the Member's appeal request within 60 days of the action or decision that is being appealed. You may contact PCSC at 505-923-5678 or toll free at 1-800-356-2219 or TTY users should call 711, with any questions. The appeal request should clearly explain the nature of the Appeal. You should include any of the following that you feel may help your appeal: medical records, medical literature, medical bills, expense records, and written statements or letters from you or a healthcare Provider.

You can submit a written appeal request letter to:

Grievance and Appeals Coordinator
P.O. Box 27489
Albuquerque, NM 87125-7489

Or Fax to: 505-923-5124

You may also submit your appeal electronically

Grievance

A grievance is an oral or written complaint expressing dissatisfaction submitted by or on behalf of a covered grievant which includes but is not limited to:

  • Availability, delivery or quality of healthcare services
  • Being able to reach someone by phone or get the information you need
  • Cleanliness of condition of the doctor’s office

How to file a Grievance:

If you have a complaint, we encourage you to first call Presbyterian Customer Service Center (PCSC) at 505-923-5678 or toll free at 1-800-356-2219 or TTY users should call 711, Monday through Sunday 7 a.m. to 6 p.m. with any questions. We will try to resolve any complaint that you might have over the phone, or, you may submit a written complaint. We have a formal procedure to review your complaints. We call this our formal grievance process. Once we receive your grievance, Presbyterian Health Plan will write you to let you know how we have addressed your concern within the timeframes specified in your plan specific member handbook. In some instances, we may need additional time to address your concern. If additional time is needed, we will keep you informed of how your grievance is being handled. No matter which process you use to notify Presbyterian Health Plan, we must keep track of all grievances or complaints in order to report our data to regulatory bodies and to our members, upon request.

You may send your grievance request letter to:

Grievance and Appeals Coordinator
P.O. Box 27489
Albuquerque, NM 87125-7489

Or Fax to: 505-923-5124

You may also submit your grievance electronically

Pharmacy Exceptions

How can you request an exception to the Plan's formulary (drug list)?

You can ask us to make an exception to our coverage rules. Depending on your plan, there are several types of exceptions that you can ask us to make.

You can ask us to cover your drug even if it is not on our formulary.

You can ask us to waive coverage restrictions or limits on your drug, if your plan allows it. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.

Presbyterian utilizes clinical evidence from appropriate external organizations in developing the criteria used in decisions and exceptions. We involve pharmacists and appropriate practitioners in our review of criteria and procedures.

To request an exception, you or your appointed representative should call Presbyterian Customer Service Center (PCSC) at 505-923-5678 or toll free at 1-800-356-2219 or TTY users should call 711, Monday through Sunday 7 a.m. to 6 p.m. Your doctor can also fax a request to: 505-923-5540 or exception requests may be mailed to:

PHP Pharmacy Department
P.O. Box 27489
Albuquerque, NM 87125-7489

Coverage Determination Decisions

A coverage determination decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from a doctor or if your network doctor refers you to a medical specialist.

Your doctor can contact us and ask for a coverage determination decision if your doctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think that you need.

We are making a coverage determination decision for you whenever we decide what is covered for you and how much we will pay for the medical service. In some cases we might decide that a service or drug is not covered or is no longer covered under your plan. If we make a coverage determination decision and you are not satisfied with the decision, you can "appeal" the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.

How to get help with a coverage determination

Would you like some help? Here are resources you may wish to use if you decide to ask for any kind of coverage decision or appeal a decision:

  1. You can call Presbyterian Customer Service Center (PCSC) at 505-923-5678 or toll-free, 1-800-356-2219 or TTY users should call 711, Monday through Sunday 7:00 am to 6:00 pm
  2. Your doctor can make a request for you.
  3. You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your "representative" to make an appeal. There may be someone who is already legally authorized to act as your representative under State law.
  4. You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of coverage decision or appeal a decision.
Visit the Forms & Documents library to find your plan specific handbook.