New Mexico Billing Rights
Additional State-Law Protections for Patients with State-Regulated Health Plans
Under New Mexico’s “Surprise Billing Protection Act”:
- Nonparticipating providers (including health care professionals, hospitals, or other facilities licensed to furnish healthcare services) may not knowingly submit a surprise bill to a covered person.
- A “surprise bill” is a bill that a nonparticipating provider issues to a covered person for health care services rendered in the following circumstances, in an amount that exceeds the covered person’s cost-sharing obligation that would apply for the same health care services if these services had been provided by a participating provider:
- emergency care provided by the nonparticipating provider; or
- health care services, that are not emergency care, rendered by a nonparticipating provider at a participating facility where:
- a participating provider is unavailable;
- a nonparticipating provider renders unforeseen services; or
- a nonparticipating provider renders services for which the covered person has not given specific consent for that nonparticipating provider to render the particular services rendered
- A “surprise bill” is a bill that a nonparticipating provider issues to a covered person for health care services rendered in the following circumstances, in an amount that exceeds the covered person’s cost-sharing obligation that would apply for the same health care services if these services had been provided by a participating provider:
- The following are not considered “surprise bills”:
- Health care services received by a covered person when a participating provider was available to render the health care services and the covered person knowingly elected to obtain the services from a nonparticipating provider without prior authorization
- Health care services rendered by a nonparticipating provider to a covered person whose coverage is provided pursuant to a preferred provider plan; provided that the health care services are not provided as emergency care or for services rendered pursuant to Subparagraph (b) of Paragraph (1) of this subsection.
- A “facility is an entity providing health care services that includes a laboratory, a health care provider’s office or clinic; a general, special, psychiatric or rehabilitation hospital; an ambulatory surgical center; a cancer treatment center; a birth center; an inpatient, outpatient or residential drug and alcohol treatment center; diagnostic or other outpatient medical service or testing center; an urgent care center; a freestanding emergency room; any other therapeutic health care setting
Filing a Complaint
If you get a bill from an out-of-network provider that you do not believe is owed, contact the New Mexico Office of Superintendent of Insurance – www.osi.state.nm.us or 855-4ASK-OSI (855-427-5674).
State Agency Contact Information
New Mexico Office of Superintendent of Insurance
Phone: 855-4-ASK-OSI (855-427-5674)
Website: www.osi.state.nm.us/pages/bureaus/consumer/resources/consumer-assistance
Additional Information
Visit www.cms.gov/nosurprises/consumers or call 800-985-3059 for more information about your rights under federal law.