TITLE 13 INSURANCE
CHAPTER 10 HEALTH INSURANCE
PART 33 SURPRISE BILLING
13.10.33.1 ISSUING AGENCY: New Mexico
Office of Superintendent of Insurance (“OSI”).
[13.10.33.1
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13.10.33.2 SCOPE: These rules
apply to every health insurance carrier (“carrier”) that provides health
coverage under a policy, arrangement, contract or plan described in Section 59A-57A-12 NMSA 1978.
[13.10.33.2
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13.10.33.3 STATUTORY AUTHORITY: Section 59A-2-9
NMSA 1978, Sections 59A-57A-1 through 59A-57A-13 NMSA 1978 and Section 59A-16-21.3
NMSA 1978.
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13.10.33.4 DURATION: Permanent.
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13.10.33.5 EFFECTIVE DATE: March 1, 2021,
unless a later date is cited at the end of a section.
[13.10.33.5
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13.10.33.6 OBJECTIVE: To implement
consumer protection, reimbursement, refund, reporting and appeal requirements
for the surprise billing protection act.
[13.10.33.6
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13.10.33.7 DEFINITIONS: For definitions
of terms contained in this rule, refer to Section 59A-57A-2 NMSA 1978 and
13.10.29 NMAC.
[13.10.33.7
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13.10.33.8 REFUNDS FOR OVERPAYMENT:
A. Notice of payment and right to a refund.
A carrier who reimburses a provider for a surprise bill shall provide the
covered person an explanation of benefits (“EOB”) showing, at a minimum, the
name of the provider, the date of service, the amount billed and the amount
paid. As of June 1, 2021, the first page of the EOB shall provide a surprise
billing explanation of benefits and rights and contain the following statement
in bold and of at least 12 point type:
SURPRISE
BILLING – YOU RECENTLY VISITED A PROVIDER WHO IS NOT IN YOUR PLAN’S NETWORK. IF
YOU HAVE ALREADY PAID THE PROVIDER MORE THAN YOU OWE, THE PROVIDER OWES YOU A
REFUND WITHIN 45 DAYS OF THE DATE THE
PROVIDER RECEIVED OUR PAYMENT. IF YOU DO NOT RECEIVE A REFUND WITHIN THAT 45-DAY PERIOD, YOU MAY FILE AN APPEAL WITHIN 180
DAYS AFTER EXPIRATION OF THE 45-DAY PERIOD AT WWW.OSI.STATE.NM.US
OR
1-855-427-5674.
B. Issuance of the EOB. A carrier shall
issue the EOB within 15 days of the payment.
C. Payment notice to
provider. A carrier who reimburses a surprise bill shall inform the out-of-network
provider of the in-network cost-sharing amount owed by the covered person. Any notice
of the covered person’s cost-sharing responsibility shall refer to New Mexico’s
surprise billing protections act and the provider rights granted therein.
D. Appeal process. A
covered person may appeal a provider’s failure to make a timely or complete
refund of an excess payment using the surprise billing appeal form on OSI’s
website.
(1) The
appeal must be filed within 180 days after the expiration of the 45-day period
in which the provider was required to refund the covered person’s excess payment.
(2) The
provider shall have 30 days to respond to the appeal in writing.
(a) A provider’s
failure to timely respond shall result in an order from the superintendent directing
the provider to pay the full amount of the claimed refund.
(b) If a provider timely
responds to a refund appeal, the superintendent shall resolve the appeal
following the rules that govern informal hearings. If the superintendent
determines that a provider owed a refund, the superintendent shall order the
provider to pay the refund amount with interest pursuant to Section 59A-16-21.1
NMSA 1978.
E. EOB Alternative.
A carrier may file with the superintendent, and request approval to use, an
alternate form or style of surprise billing EOB. The superintendent shall
approve the alternate EOB if it is at least as likely to convey a member’s
rights under the Surprise Billing Act as the EOB required by Subsection A of
this rule.
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13.10.33.9 COVERED PERSON RIGHTS: A carrier
shall afford a covered person these rights:
A. Out of state care. A
carrier shall reimburse a surprise medical bill as required by law regardless
of the situs of delivery of the medical care, including medical care rendered
out-of-state.
B. Specific consent. For purposes of
Subparagraph (b) of Paragraph (1) of Subsection Y of Section 59A-57A-2 NMSA 1978,
“specific consent” shall only be valid if the covered person has a meaningful
choice between a participating provider and a nonparticipating provider; the
covered person was not encouraged or coerced by a network provider or the
carrier into selecting the out-of-network provider; and the covered person
signs a notice and disclosure statement, at least five days before the service
or supply is received, acknowledging that the covered person may be liable for
a balance bill and chooses to receive the service or supply.
C. Notice of Rights. A
carrier shall provide each covered person with notice of surprise billing
protection act rights in the plan’s evidence of coverage and as directed by the
superintendent in a bulletin.
[13.10.33.9
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13.10.33.10 PROVIDER CLAIM SUBMISSION: An
out-of-network provider shall not bill a covered person for a potential
surprise bill without first submitting the bill to the covered person’s
designated carrier and obtaining a payment or denial.
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13.10.33.11 REPORTS REQUIRED: A carrier shall
annually submit a surprise billing data report using a template provided by the
superintendent. The template shall require a carrier to report changes to the
percent of claims paid for emergency services. The report shall be filed annually
by May 1st of each year and shall contain data from the full prior calendar year.
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13.10.33.12 PROVIDER COMPLAINTS: A provider may dispute
the denial, or reimbursement amount, of a surprise bill pursuant to the
applicable procedures in 13.10.16 NMAC.
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13.10.33.13 SEVERABILITY: If any section
of this rule, or the applicability of any section to any person or
circumstance, is for any reason held invalid by a court of competent
jurisdiction, the remainder of the rule, or the applicability of such
provisions to other persons or circumstances, shall not be affected.
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History of
13.10.33 NMAC: [RESERVED]