PATIENT APPEAL PROCESS & APPEAL REQUEST FORM - UNM Care and Out-of-County Care Programs

Sep 16, 2026

Uploaded by Kurz

This document provides instructions for appealing a denial of eligibility for UNM Care or Out-of-County Care programs. It explains appeal timing (submission within 45 days), the appeal review by the Appeal Committee, and the timeline for receiving a decision after UNM Hospitals receives the letter. It also outlines a second-level appeal to the Executive Appeals Committee, including how to request it, what information will be re-evaluated, and the responsibility for medical bills during review.

LanguageEnglish

CategoryForms

FormatPDF

Pages4

Reading Time2 min

AccessFree to download

Patient Appeal Process & Appeal Request Form

Eligibility denial appeals

Appeal Committee review

Executive Appeals Committee (second appeal)

Appeal Request Form fields

PATIENT APPEAL PROCESS & APPEAL REQUEST FORM for UNM Care and Out-of-County Care Programs You have the right to appeal the denial of your UNM Care or Out-of-County Care application. If you were denied, but you believe there are reasons you should qualify for UNM Care or Out-ofCounty Care, you can ask for your application to be reconsidered (or appeal the decision) . You must send your appeal letter within 45 days from the date you were found ineligible. At the end of your appointment or after you have submitted all of the required documents, the Financial Assistance team will notify you if you are approved or denied UNM Care or Out-ofCounty Care. If we determine that you are denied, you will get a letter that explains the reason for the denial. You can appeal if you disagree with the reason for the denial. Some examples include: ● You feel your condition will result in significant bills in the upcoming year that you can not afford, OR ● You believe your treatment or procedure is medically necessary, OR ● There is a good reason that you should get benefits that you think we did not consider. Instructions and Process for Appeal 1 Please complete the attached Appeal Request Form and gather any additional information or documents you want to be considered in your appeal. Be sure to include any special circumstances in your life that have made it difficult for you to be able to afford medical care. You must send your appeal within 45 days from the date your application was denied. You can either mail or email your appeal request form and any additional documents to: Representative Albuquerque, NM 87xxx OR email to [FinancialAssistance@salud.unm.edu](FinancialAssistance@salud.unm.edu) or to your representative All appeal letters are reviewed by the Appeal Committee. The Appeal Committee will consider your appeal request form and any additional documents you sent, your medical bills, your medical history, UNMH policy, the reason for the denial, and then re-evaluate your eligibility. You will be informed of whether your appeal has been approved or not within 30 days after UNM Hospitals has received the appeal letter. Instructions and Process for Appeal 2 If your appeal is denied, you will receive a letter of denial with an explanation. This second letter of denial will give you the option of appealing to the Executive Appeals Committee. You can request this appeal by calling the Patient Financial Assistance Representative you met with during your appointment at 505-272-2521 and telling them you would like your denial to be reevaluated by the Executive Appeals Committee. You do not need to send any other forms or documentation, but if there is additional information you would like to be considered, send it to: Executive Appeals Committee 1131 University N.E. Suite D Albuquerque, NM 87102 The denials will be re-evaluated by the Executive Appeals Committee, who will consider your Appeal Request Form and any additional information and documents you sent, your medical bills, your medical history, UNMH policy, the reason for your denial, and your current and future financial medical and financial situation. You will receive a written response to this Executive Appeal letting you know if your appeal is approved or if the original denial has been upheld. Please be aware that you will still be responsible for any bills while your case is under review. You may contact 505-272-2521 to set up payment arrangements. The Appeal Request Form is on the next page. Appeal Request Form To request an appeal, please complete the form below or answer the questions on a separate piece of paper. Include as much detail as possible. Feel free to attach additional sheets of paper if you need more space. Please complete this form in the language you are most comfortable with. Today’s Date: Patient’s Name: Date of Birth: Medical Record Number: Date on your UNM Care or Out-of-County Care denial letter: Wh

FAQs

How long do you have to submit an appeal for UNM Care or Out-of-County Care?

Send your appeal letter within 45 days from the date you were found ineligible or from the date on your denial letter.

What does the Appeal Committee consider when reviewing your appeal?

The Appeal Committee reviews your Appeal Request Form and any additional documents, your medical bills and history, UNMH policy, and the stated reason for the denial, then re-evaluates eligibility.

How do you request a second appeal if your first appeal is denied?

Call the Patient Financial Assistance Representative at 505-272-2521 to ask for reevaluation by the Executive Appeals Committee; no additional forms are required unless you want to submit extra information, bills, or documents.

Are you responsible for medical bills while your appeal is under review?

Yes. You remain responsible for any bills while the case is being reviewed, and you may contact 505-272-2521 to set up payment arrangements.

Sep 16, 2026

Uploaded by Kurz