New Mexico Administrative Code
Title 13 - INSURANCE
Chapter 10 - HEALTH INSURANCE
Part 33 - SURPRISE BILLING
Section 13.10.33.8 - REFUNDS FOR OVERPAYMENT
Current through Register Vol. 35, No. 6, March 26, 2024
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.
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.
