Appeals & Grievances
Presbyterian welcomes feedback from our providers. We have comprehensive processes implemented, in conjunction with our regulatory agencies, to ensure that our members and providers have grievances and appeals rights.
Practitioners and providers have the right to file an appeal if he/she is dissatisfied with a decision made by Presbyterian to terminate, suspend, reduce or not provide approved services to a member or to deny payment for services, and if the provider disagrees with any policy or adverse action made by Presbyterian. Additionally, if a provider/practitioner is dissatisfied with any of Presbyterian’s general operations, he/she may file a Grievance.
Providers have one year (12 months) from the date of service to file an appeal for a denied claim.
Pharmacies/Pharmacists Appeals and Grievances
Presbyterian Health Plan and Presbyterian Insurance Company, Inc. manages all appeals and grievances for providers related to coverage determinations and the formulary review process.
Prior Authorizations
Certain specialized services and prescription drugs require a prior authorization or inpatient notification before being rendered to patients and members.
For pharmacy related prior authorization information visit our Authorizations page
Policies and Procedures Appeals and Grievances
Effective January 1, 2024, Capital Rx will be the Pharmacy Benefits Manager (PBM) for Presbyterian. Capital Rx manages all appeals and grievances for Pharmacies and Pharmacists that relate to policies and procedures in accordance with participating pharmacy provider network agreements including the following:
Term definitions
Contract information
Processing Claims
BIN information
Compliance, fraud, waste, and abuse (FWA)
Pharmacy network participation requirements
Payment and remittance questions
NOTE: Capital Rx does not use any maximum allowable cost (MAC) pricing structures as part of its reimbursement models. Reimbursement is determined based on the National Average Drug Acquisition Cost (NADAC) list published by the Centers for Medicare and Medicaid Services (CMS). Capital Rx does not set the NADAC unit price. If the NADAC unit price is below the pharmacy acquisition cost, please follow the process CMS has set up for NADAC pricing concerns.
NADAC Help Desk
The NADAC Help Desk can be contacted through the following (NOTE: The Help Desk is managed by Myers & Stauffer, LC. CMS has a contract with Myers & Stauffer, LC, to perform a Retail Price Survey.):
Toll-free phone: (855) 457-5264 Pharmacy Provider Manual (cap-rx.com)
For claims prior to January 1, 2024, Pharmacies or Pharmacists can submit MAC Appeal Requests by visiting the OptumRx website here: MAC appeal submission guide (optumrx.com)
Should a pharmacy or pharmacist disagree with any policy, decision or adverse action made by Presbyterian, they can contact the Provider CARE Unit at 505-923-5757 or 1-888-923-5757 or your Provider Network Management Relationship Executive.
Provider Grievances for Interagency Benefits Advisory Committee (IBAC), Fully-Insured and Commercial Plans
Providers have the right to present oral or documentary evidence to a Presbyterian committee review panel responsible for the substantive area addressed by the concern. If the grievance raises a quality-of-care concern the panel will include a New Mexico-licensed medical professional who practices in the general area of concern. Presbyterian will issue a decision to the provider pursuing a grievance within 45 calendar days after the committee has obtained all information concerning the provider’s grievance. No person with a conflict of interest will participate in a decision to resolve a grievance. For a list of the applicable regulations, please refer to the Applicable Appeal and Grievance Regulations.
Regulations Relevant to Appeal and Grievance Policies and ProceduresAppeals & Grievances on Behalf of Members
If an issue involves a Utilization Management decision, a practitioner or provider must obtain the written consent of the member to act on his/her behalf during the appeal process, unless the matter is determined to be an Expedited Appeal.
Detailed information on the appeals and grievances processes are provided in the following documents:
Should a provider/practitioner disagree with any policy, decision or adverse action made by Presbyterian, he/she should contact the Provider CARE Unit at 505-923-5757 or 1-888-923-5757 or your Provider Network Management Relationship Executive. They will put you in touch with the appropriate audience to hear your appeal. Appeals are heard by:
Issue | Contact |
|---|---|
Appeal of Utilization Management decisions with written consent from the member | Member Appeals and Grievances Coordinator |
Appeal of denial, suspension or termination of network participation and initiation of Fair Hearing Plan | Credentialing Subcommittee |
Expedited Appeal requests on behalf of a member | Member Appeals and Grievances Coordinator |
Dispute of claims adjudication | CARE Unit Specialist |
Challenge of any other adverse action, decision or policy | Provider Appeals and Grievances Coordinator |
Initiation of a Level II Provider Appeal Hearing | Provider Appeals and Grievances Coordinator |
