Detailed Answer
North Carolina Rule 414 is part of the North Carolina Industrial Commission’s fee schedule and does not apply in New Mexico. In New Mexico, insurance adjusters must follow the New Mexico Insurance Code and administrative rules. Under NMSA 1978, §59A-16-30, insurers must reimburse health-care providers based on reasonable and customary charges. See NMSA 1978, §59A-16-30.
An adjuster in New Mexico cannot unilaterally apply an out-of-state fee schedule or reduce your medical bills under North Carolina’s Rule 414. If your insurer reduces payments, it must cite a New Mexico statute or rule and follow due process. You can request a detailed explanation from your insurer. If you believe the adjustment violates New Mexico law, you may file a complaint with the Office of Superintendent of Insurance under NMSA 1978, §59A-16-31. See NMSA 1978, §59A-16-31.
Helpful Hints
- Review your Explanation of Benefits (EOB) for the insurer’s legal citation.
- Ask your provider to submit a certified bill if the adjuster challenges billed amounts.
- Request a written appeal if you disagree with the insurer’s reduction.
- Keep detailed records of all medical services and communications with your insurer.
- Contact the New Mexico Office of Superintendent of Insurance for guidance on disputes.
Disclaimer: This article is for informational purposes only and does not constitute legal advice. Consult a licensed attorney in New Mexico for advice on your specific situation.