DATA CALL PURSUANT TO THE SURPRISE BILLING PROTECTION ACT (ACT), NMSA 1978, CHAPTER 59A, ARTICLE 57A OF THE INSURANCE CODE

STATE OF NEW MEXICO OFFICE OF SUPERINTENDENT OF INSURANCE SUPERINTENDENT OF INSURANCE Alice T. Kane Main Office: 1120 Paseo de Peralta, Fourth Floor, Santa Fe, NM 87501 Satellite Office: 6200 Uptown Blvd NE, Suite 400, Albuquerque, NM 87110 Main Phone: (505) 827-4601 | Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us BULLETIN 2024-020 October 2, 2024 TO: ALL HEALTH CARE CARRIERS LICENSED IN NEW MEXICO SUBJECT TO SURPRISE BILLING PROTECTIONS ACT RE: DATA CALL PURSUANT TO THE SURPRISE BILLING PROTECTION ACT (ACT), NMSA 1978, CHAPTER 59A, ARTICLE 57A OF THE INSURANCE CODE Pursuant to NMSA 1978, Section 59A-57A-l1 of the Act, the Superintendent of Insurance (Superintendent) “may require health insurance carriers” to “report the annual percentage of claims and expenditures paid to nonparticipating providers for health care services,” to monitor the effectiveness of the requirements in the Act, and the impact on provider networks and health care costs. This monitoring requires establishment of a data baseline pre-enactment of the Surprise Billing Protection Act in 2020. 13.10.33.11 NMAC requires carriers to submit a surprise billing data report using a template provided by the Superintendent. The rule requires carriers to file this report annually by May 1 of each year. The report is required to contain data from the full prior calendar year. OSI has significantly changed the Surprise Billing Data Call Template and with carrier’s feedback we believe we have a more accurate and technically formatted template that will ease the burden for capturing the data electronically. Below is a list of the changes made to help understand the differences between the two versions. The new Surprise Billing Data Call Template can be found on OSI’s website at the following link: Office of Superintendent of Insurance (state.nm.us) B U L L E T I N 2 0 2 4 - 0 2 0 P a g e | 2 Main Office: 1120 Paseo de Peralta, Fourth Floor, Santa Fe, NM 87501 Satellite Office: 6200 Uptown Blvd NE, Suite 400, Albuquerque, NM 87110 Main Phone: (505) 827-4601 | Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us List of changes to the surprise billing data call template: 1. Changed the periods in the report to be annual rather than by quarter. 2. Removed the Network terminations initiated (total count) section. 3. Removed the Percent change in all emergency care claims section. 4. Removed the % of surprise billing reimbursement rate of median in-network paid claims section. 5. Removed provider specialties that were redundant and/or not necessary for evaluation. 6. Added summary level metrics to the first tab called “Carrier and Summary Information” 7. Reformatted the tables for easier data entry. 8. Created separate templates for Emergency and Non-Emergency to reduce the complexity of the template. Categories within each report were designed to capture the distinct types of out-of-network care are as follows (each claim should be reported only once): a. Emergency i. Out-of-network Claims for Emergency Services b. Non-Emergency i. Non-Emergency Out-of-Network Claims at an In-Network Facility ii. Out-of-Network Claims Due to In-Network Provider Not Available for Medically Necessary Services iii. Other Out-of-Network (Including Member Preference) 9. Added the following fields to capture more information regarding the impact to members: a. Number of unique members b. Allowed amount c. Patient share d. Number of claims denied PLAN YEAR 2023 Every subject carrier in operation in 2023 shall furnish the information and data for the same plan year 2023 in the newly revised Surprise Billing Data Call Template is found on the OSI website at: Office of Superintendent of Insurance (state.nm.us) 1. First tab: Carrier and Summary Information, complete this tab entirely. 2. Second tab: Instructions for completing the template are on the second tab of the spread sheet template. 3. The filing is due by December 1, 2024. 4. This information shall be submitted via SERFF using the following instructions: a. TOI: H21- Health – Other b. Sub TOI: H21.000 Health-Other c. Filing Type: Informational d. The Project Name: 2023 Surprise Billing Data Call e. The Requested Filing Mode: Informational B U L L E T I N 2 0 2 4 - 0 2 0 P a g e | 3 Main Office: 1120 Paseo de Peralta, Fourth Floor, Santa Fe, NM 87501 Satellite Office: 6200 Uptown Blvd NE, Suite 400, Albuquerque, NM 87110 Main Phone: (505) 827-4601 | Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us f. Template Naming Convention: [carrier name] [plan type] [PY2023][name of report][date created][version #(if necessary)] i.e.: PHP_HMO_PY2023_Surprise Billing Data Call_12.01.2024 Filing should be submitted as ‘Informational’ under the above-named TOI and Sub-TOI. The “Project Name” field should be named as noted above with the plan year of the data mentioned first. A separate SERFF filing should be submitted for each plan year reported. PLAN YEARS 2019 and 2020 The data collected in prior plan years 2019 and 2020 is not sufficient to OSI as the template to capture the required data unfortunately did not meet the compliance needs for this law as compared to the new format we have now. OSI needs the data from previous years to compare to current years to better understand the whole outcome. Therefore, every carrier is ordered to complete the new Surprise Billing Data Call template for plan years 2019 and 2020. OSI and the Superintendent of Insurance appreciate your time and effort to capture this data again. 1. First tab: Carrier and Summary Information, complete this tab entirely. 2. Second Tab: Instructions for completing the template are on the second tab of the spread sheet template. 3. The filing is due by January 6, 2025. 4. This information shall be submitted via SERFF using the following instructions: a. TOI: H21- Health – Other b. Sub TOI: H21.000 Health-Other c. Filing Type: Informational d. The Project Name: 20xx Surprise Billing Data Call e. The Requested Filing Mode: Informational f. Template Naming Convention: [carrier name] [plan type] [PY20xx] [name of report] [date created] [version # (if necessary)] i.e.: PHP_HMO_PY2019_Surprise Billing Data Call_1.06.2025 Filing should be submitted as ‘Informational’ under the above-named TOI and Sub-TOI. The Project Name field should be named as noted above with the plan year of the data mentioned first. A separate SERFF filing should be submitted for each plan year reported. B U L L E T I N 2 0 2 4 - 0 2 0 P a g e | 4 Main Office: 1120 Paseo de Peralta, Fourth Floor, Santa Fe, NM 87501 Satellite Office: 6200 Uptown Blvd NE, Suite 400, Albuquerque, NM 87110 Main Phone: (505) 827-4601 | Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us The data collection for Plan Years 2021 and 2022 which was due May 1, 2023, was not collected. Therefore, a second phase to capture data for these plan years will be announced in a future bulletin. Failure to submit complete and correct information requested in this bulletin by the indicated deadlines may result in a penalty pursuant to NMSA 1978, Section 59A-1-18. If you have any questions regarding this bulletin, please contact Brenda Newell, Compliance Officer Supervisor at brenda.newell@osi.nm.gov with the Office of Superintendent of Insurance. As always, the Office of Superintendent of Insurance thanks carriers for their partnership and cooperation. ISSUED this 2nd day of October 2024. __________________________________ ALICE T. KANE Superintendent of Insurance