Balance Billing Protections
As a member of Presbyterian Health Plan, you have balance billing protections under the federal No Surprises Act (NSA) as well as the NM Surprise Billing Protection Act.
If you receive care under any of the circumstance below from a provider who is not in your network, these are your rights:
If you receive emergency care out-of-network, including air ambulance service:
You are only responsible for paying what you would owe for the same care from an in-network provider or facility.
You do NOT need to get prior authorization for emergency services.
Your care can continue until your condition has stabilized. If you require additional care after stabilization, call us at 505-923-5678 and we will help you receive that care from an in-network provider.
You cannot be balance billed.
If you receive care from an out-of-network provider at an in-network facility, such as a hospital that is in your plan, you are only responsible for paying what you would owe for the same care from an in-network provider if:
You did not consent to services from an out-of-network provider,
Were not offered the service from an in-network provider, or
The service was not available from an in-network provider – as determined by your health care provider and your health insurance company.
If you get a bill from an out-of-network provider under any of the above circumstance that you do not believe is owed:
Call us first at 505-923-5678. We will try to resolve the issue with the provider on your behalf.
Contact the New Mexico Office of Superintendent of Insurance if the problem has not been resolved by us – www.osi.state.nm.us or 1-855-4ASK-OSI (1-855-427-5674). If you are a Federal employee, you may contact the Department of Health and Human Services at www.cms.gov/nosurprises or 1-800-985-3059.
To help stop improper out-of-network bills, we will:
Notify you if your provider leaves our network and allow you transitional care with that provider at the in-network benefit level for up to 90 days depending on your condition and course of treatment.
Verify the accuracy of our provider directory information at least every 90 days.
Confirm whether a provider is in-network if you contact us at 505-923-5678. If our representative provides inaccurate information that you rely on in choosing a provider, you will only be responsible for paying your in-network cost sharing amount for care received from that provider.
You have the right to receive notice of the following before you receive out-of-network care at an in-network facility:
A good faith estimate of the charges for out-of-network care.
At least five days to change your mind before you receive a scheduled out-of-network service. If you choose to receive out of network care you will be responsible for out-of-network charge that we do not cover.
A list of in-network providers and the option to be referred to any such provider who can provide necessary care.
If you pay an out-of-network provider more than we determine you owe:
The provider will owe you a refund within 45 days of receipt of payment by us.
If you do not receive a refund within that 45-day period, the provider will owe you the refund plus interest.
You may contact the New Mexico Office of Superintendent of Insurance at www.osi.state.nm.us and 1-855-4ASK-OSI (1-855-427-5674) for assistance or to appeal the provider’s failure to provide a refund. You need to file the appeal within 180 days of the 45-day refund period expiration.
Visit www.cms.gov/nosurprises for more information about your rights under federal law.