What is an internal appeal?
An internal appeal asks the health carrier to reconsider an adverse determination—when the plan says care is not medically necessary, experimental, or investigational, or denies a claim or PA.
This is different from external review, where OSI appoints an independent review organization (IRO) after internal review is complete (with limited urgent exceptions).
General walkthrough: Appeals roadmap.
New Mexico appeal timelines
Filing deadline
- Appeal within 180 days of the adverse determination (13.10.17.14 NMAC; notice requirements in 13.10.17.12 NMAC)
- Carrier must acknowledge your request within 3 days and provide a contact person (13.10.17.14 NMAC)
- Full and fair review: access to the file, evidence submission, and relevant policies at least 5 days before review (13.10.17.14 NMAC)
- Medical necessity appeals reviewed by clinical peers in the same or similar specialty
Decision deadlines
- Standard — before service: first-level review (and any required internal panel) within 30 days of the request
- Standard — after service (post-service claim): within 60 days
- Expedited: within 72 hours when urgent; ongoing services may continue during inpatient or approved treatment appeals (13.10.17.14 NMAC)
If the carrier is late
If the carrier misses required internal review deadlines (unless you agreed to postpone), the requested service is deemed approved when it reasonably appears to be a covered benefit (13.10.17.14 NMAC, Subsection H). Late internal review may also let you proceed to external review (13.10.17.19 NMAC).
State employee plans
If you are covered under the New Mexico Health Care Purchasing Act (state employees and retirees), you may need an additional internal panel review and review by your specific review board before OSI external review (13.10.17.18 NMAC).
How to file
- Read the denial for appeal instructions and deadlines.
- Submit in writing when possible—use forms included in your denial notice.
- Include clinical support and request copies of records the carrier used.
- Request expedited review if delay would cause serious harm.
- Keep copies of everything sent and the date sent.
Carrier links: New Mexico prior auth & internal appeals links.
Evidence that helps
- Treating clinician letter on medical necessity
- All records the carrier relied on—or should have considered
- Peer-reviewed literature for experimental/investigational disputes
Medicaid appeals
Centennial Care managed care requires an MCO appeal before a state fair hearing:
- MCO appeal: typically 60 calendar days from the notice of action (federal Medicaid rules)
- MCO must resolve standard appeals within about 30 days (extensions possible with notice)
- State fair hearing: request to the HCA Office of Fair Hearings within 90 calendar days of the MCO's final appeal decision (often 30 days if the MCO appeal was expedited)
- For continuation of benefits during the fair hearing, request within 10 days of the MCO denial letter
After internal appeal
If you receive a final denial, request external review from OSI within four months of the final internal determination (13.10.17.15 NMAC).
Next: New Mexico external review.