N.M. Admin. Code § 13.10.33.8

Current through Register Vol. 35, No. 23, December 10, 2024

Section 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.

N.M. Admin. Code § 13.10.33.8

Adopted by New Mexico Register, Volume XXXII, Issue 02, January 26, 2021, eff. 3/1/2021