This is a communication from a debt collector.
This is an attempt to collect a debt. Any information obtained will be used for that purpose.
A health insurance carrier shall not require that prior authorization for emergency care be obtained by or on behalf of, a covered person prior to the point of stabilization of that covered person if a prudent layperson would reasonably believe that the covered person requires emergency care. N.M. Stat. Ann. § 59A-57A-3B.
Pursuant to N.M. Stat. Ann. § 59A-57A-4A, other than applicable cost sharing that would apply if a participating provider had rendered the same services, a health insurance carrier shall provide reimbursement for and a covered person shall not be liable for charges and fees for covered non-emergency care rendered by a nonparticipating provider that are delivered when:
• the covered person at an in-network facility does not have the ability or opportunity to choose a participating provider who is available to provide the covered services; or
• medically necessary care is unavailable within a health benefits plan’s network; provided that “medical necessity” shall be determined by a covered person’s provider in conjunction with the covered person’s health benefits plan and health insurance administrator.
Pursuant to N.M. Stat. Ann. § 59A-57A-5:
• A nonparticipating provider shall not knowingly submit a surprise bill to a covered person.
• In accordance with the hearing procedures established pursuant to the Patient Protection Act, a covered person may appeal a health insurance carrier’s determination made regarding a surprise bill.
• Beginning July 1, 2020, the department of health shall require each health facility licensed pursuant to the Public Health Act to post the following on the health facility’s website in a publicly accessible manner:
• the names and hyperlinks for direct access to the websites of all health insurance carriers with which the hospital has a contract for services;
• a statement that sets forth the following:
• services may be performed in the hospital by participating providers as well as no participating providers who may separately bill the patient;
• providers that perform health care services in the hospital may or may not participate in the same health benefits plans as the hospital; and
• prospective patients should contact their health insurance carriers in advance of receiving services at that hospital to determine whether the scheduled health care services provided in that hospital will be covered at in-network rates;
• the rights of covered persons under the Surprise Billing Protection Act [N.M. Stat. Ann. § 59A-57A]; and
• instructions for contacting the superintendent.
• Any written communication, other than a receipt of payment, from a provider or health insurance carrier pertaining to a surprise bill, shall clearly state that the covered person is responsible only for payment of applicable in-network cost-sharing amounts under the covered person’s health benefits plan. A collection agency collecting medical debt from New Mexico residents shall post a notice of consumer rights pursuant to the Surprise Billing Protection Act on its website.
• When a nonparticipating provider under nonemergency circumstances has advance knowledge that the nonparticipating provider is not contracted with the covered person’s health insurance carrier, the nonparticipating provider shall inform the covered person of the nonparticipating provider’s nonparticipating status and advise the covered person to contact the covered person’s health insurance carrier to discuss the covered person’s options.
N.M. Stat. Ann. § 59A-57A-5.
If a covered person pays a nonparticipating provider more than the in-network cost-sharing amount for services provided under circumstances giving rise to a surprise bill, the nonparticipating provider shall refund to the covered person within forty-five calendar says of receipt of payment from the health insurance carrier any amount paid in excess of the in-network cost-sharing amount. N.M. Stat. Ann. § 59A-57A-6A.
A covered person may seek recovery of the refund of the amount the covered person has paid in excess of the in-network cost-sharing amount that a nonparticipating provider owes, plus interest, pursuant to Subsection B of N.M. Stat. Ann. § 59A-57A-6 by filing an appeal with the office of the superintendent of insurance. N.M. Stat. Ann. § 59A-57A-6C.
A provider shall not knowingly submit to a covered person a surprise bill for health care services, which surprise bill demands payment for any mount in excess of the cost-sharing amounts that would have been imposed by the covered person’s health benefits plan if the health care service from which the surprise bill arises had been rendered by a participating provider. N.M. Stat. Ann. § 59A-57A-14A.
It shall be an unfair practice for a health care provider to knowingly submit a surprise bill to a collection agency. N.M. Stat. Ann. § 59A-57A-14B.
For additional information, please contact the Office of the Superintendent of Insurance at:
Office of the Superintendent of Insurance
PO Box 1689
Santa Fe, NM 87504-1689
If you have any questions about these disclosures, the practices of this site or your dealings with this site, please contact us at:
Aargon Agency, Inc.,
8668 Spring Mountain Road, Suite 110
Las Vegas, NV 89117