Salud! Part Two

In the previous newsletter, Part One, we discussed basic information about managed care Salud!.
The current article, Part Two, describes how to file a grievance in the Salud! System.

Most of the states have switched from "Fee for Service" from Medicaid to managed care. The managed care rules they must follow are different in each state. Several states require plans to notify the members of their rights to file grievances when they enroll, when th plans impose a change in service, a reduction, or a denial of service. In New Mexico, Cimarron only requires Salud! Plans to inform their members of grievance rights when they enroll (member Handbook) or when they request a hearing. Lovelace gives hearing information in their member handbook, in quarterly newsletters, and every time a formal complaint is resolved.

If you or a family member gets your medical services from the New Mexico Salud! System, you can complain if you are unhappy with the services provided. If you have already complained to the provider (doctor or professional treating you) and not gotten a satisfactory reply or solution, it may be best to complain again or ask to speak with their supervisor. It is very helpful to keep a log in order to write down the date you made a complaint, who you spoke to, and what their reply/suggested solution was (including a date by which they would call you back). A telephone call log and/or copies of correspondence sent and received are vital in building a "paper trail" which can be reproduced should you go to a due process hearing. A well-documented contact log also helps to jog our memories about what we have already done and who we spoke to about what!

If you think your health provider is not paying attention to your complaints, you can ask for the name of your treatment team coordinator. Your doctor or other health professional may not have this information but you can get it using the telephone numbers for the Salud! HMOs and BHOs provided



below. Your health provider may be willing to write a letter stating that he/she believes the service requested is a medical necessity and may be willing to file the grievance for you. Be sure that the provider that is refusing, denying, reducing or not providing the service you are requesting, has been informed by you of the concern. It may be best to try to work out your complaints with the provider before filing for a hearing, although complaining at all levels and agencies may be necessary in some cases. If you file a complaint without attempting to address it at the source of the problem, your case will not be as strong when your grievance is dealt with at a higher level.

Often it is the plan that is refusing to approve services for you. In such cases, your health care provider may not know there is a problem or may need educating about your individual circumstances.

If you have an emergency and need to expedite the grievance process, be sure to make the urgency known to the parties to which you are complaining. All three plans have a turnaround time of 72 hours to respond to the initial complaint.

When you decide to file a formal complaint or grievance in writing with your Salud! plan(either Cimarron, Lovelace, or Presbyterian), there are several ways to register your complaint. One is by filing a complaint or grievance with the Salud! plan This can be done by you, the member (the insured person), or the member's representative who could be a guardian, an advocate or someone else who can act for you. You may formally complain in writing (save a copy for yourself) to your doctor, therapist, or other provider, or you can call one of the numbers listed below, for Salud! member services under Presbyterian, Lovelace, or Cimarron. Make sure you clearly state that you are filing a "grievance". Do not forget to document in writing who you spoke to, when you spoke to them, and what they said. The Salud! member staff under all three plans must follow timelines in getting back to you. When you file your grievance, ask what the timeline is. If the person does not know, file directly with your Salud! plan's member services.

You may also directly file your grievance(or even an informal complaint) with the Medicaid office at the state level in Santa Fe. The state's Medical Assistance Division is ultimately responsible for all three Salud! plans. If your plan is not providing a service and you believe it is a medical necessity, Medicaid is an entitlement, and it is the responsibility of the Medical Assistance Division to assure that each of the plans is following proper procedures and policies.

You may request a hearing at any step of the process so that an impartial hearing officer may decide if the services will be provided. If you choose to file for a fair hearing with the State of New Mexico Human Service Department (Medical Assistance Division) Fair Hearings Bureau, call to:


Salud! Plan Complaint Phone Numbers:
Cimmaron 1-800-723-7762 (statewide)
342-4663 in Albuquerque
Lovelace Community Health Plan 1-888-815-8099 (statewide)
232-2700 in Albuquerque
Presbyterian 1-888-977-2333(statewide)
923-5200 in Albuquerque
Medical Assistance Division (505)-827-3100

When you ask for a fair hearing at the state level services must continue while the fair hearing decision is pending. Sometimes it is strategically advantageous to file with your Salud! plan, a hearing request, and the state at the same time. Every case needs to be evaluated on an individual basis for complexity of issues, timing of services and resolution, and many other factors. In any grievance or fair hearing matter, an individual can file on their own or request assistance from a friend or an advocacy agency.

In the fair hearings in which P&A has participated, we attended the hearings at the local Income Support Division office over the phone with a hearing officer from Santa Fe. The results of the hearing is sometimes known immediately during that conference call, but you will eventually get a follow-up letter summarizing the hearing results.