What Consumers need to know about Surprise Billing

State and federal law protects consumers from medical surprise billing. If you have received emergency care, (including emergency behavioral healthcare services) from a provider or a facility that is not within your plan’s network or if you are treated at an in-network facility by an out-of-network provider, surprise billing protections may apply to you.

Surprise billing can happen when you don’t have time to choose a provider and are taken to a hospital during an emergency and that hospital is not within your health plan’s provider network. (To be “in-network” means that your health plan has a contractual agreement with a provider or facility).

Surprise billing can also happen in a non-emergency situation when you receive health care services in a facility that is within your health plan network but the actual provider who provides the service is not within your plan’s network. This can occur when a consumer is unaware of the situation.

If surprise billing occurs, your health insurance may not cover the entire out of network cost which could leave you owing the difference between the out-of-network provider’s bill and the amount your health insurance paid.

The NM Surprise Billing Act will limit the amount you need to pay out of pocket to an amount that is close to what you would pay if the provider was in-network. If you have paid your health care provider more than you owe for a surprise bill, you may be entitled to a refund from the provider. In addition, consumers who do not pay a surprise bill will be protected from collections because a health care provider cannot submit a surprise bill to a collection agency.

If you get a surprise bill, contact the provider or facility and tell them you believe you’ve been wrongly billed. You can also file a complaint with our office, and we will review the matter. Your health plan should fall under our regulatory authority in order for any review to occur.

File a Complaint

If you receive a surprise medical bill, you are not responsible for paying it. Instead, your insurer must pay the out-of-network provider and/or facility directly. You are only responsible for your in-network cost-sharing amount which would include any copay, coinsurance and/or deductible amounts you may owe for the healthcare service.

Base your cost-sharing responsibility on what they would pay an in-network provider or in-network facility in your area and show the amount on your Explanation of Benefits (EOB).
Apply any amount you pay for emergency services or services provided by an out-of-network provider at an in-network facility towards your deductible and out-of-pocket limit.
Inform you, via the carrier’s website or if you ask, which providers, hospitals and facilities are in your plan network.
Provide notice to you detailing your rights under the Surprise Billing Protection Act and inform you when you cannot be balanced billed for a surprise bill.

NMSA 59A- Article 57- Patient Protection

NMAC Title 13 Chapter 10 Health Insurance – Part 33 – Surprise Billing

NMSA 59A – Article 16 – Trade Practices and Fraud

Mandatory Reporting Requirements Under the New Mexico Insurance Fraud Act

This notice serves as an official reminder that all insurers and licensed insurance professionals are required to comply with the mandatory reporting and cooperation requirements established under the New Mexico Insurance Fraud Act. These obligations are ongoing and apply to every insurer, adjuster, producer, and insurance professional conducting business within the State of New Mexico. […]

What Consumers need to know about Surprise Billing

OSI Events Calendar

Recent News

REPEAL OF BULLETIN NO. 2023-009

REPEAL OF BULLETIN NO. 2018-013

Mandatory Reporting Requirements Under the New Mexico Insurance Fraud Act