N.Y. Comp. Codes R. & Regs. tit. 23 § 400.10

Current through Register Vol. 46, No. 45, November 2, 2024

Section 400.10 - Payment for the independent dispute resolution

(a)Disputes involving an insured.

(1) If an IDRE determines the health care plan's payment, or best and final offer, as applicable, is reasonable, payment for the dispute resolution process shall be the responsibility of the non-participating physician, non-participating hospital, or as applicable, nonparticipating referred health care provider.

(2) If an IDRE determines the non-participating physician's or non-participating referred health care provider's fee or the non-participating hospital's fee or best and final offer, as applicable, is reasonable, payment for the dispute resolution process shall be the responsibility of the health care plan.

(3) If good faith negotiations directed by the IDRE results in a settlement between the health care plan and the non-participating physician, non-participating hospital or non-participating referred health care provider, the health care plan and the non-participating physician, non-participating hospital or non-participating referred health care provider shall evenly divide and share the prorated cost for dispute resolution.

(4) For disputes that are rejected as ineligible or due to the requesting non-participating physician, nonparticipating hospital, nonparticipating referred health care provider or health care plan's failure to submit information, an IDRE may charge an application processing fee, which shall be the responsibility of the requesting physician, hospital, health care provider or health care plan.

(b)Disputes involving a patient who is not an insured.

(1) If an IDRE determines the physician's or hospital's fee is reasonable, payment for the independent dispute resolution process shall be the responsibility of the patient. If the superintendent determines that payment would pose a hardship to the patient pursuant to subdivision (c) of this section, the IDRE shall waive payment for the dispute resolution process.

(2) If an IDRE determines the physician's or hospital's fee is not reasonable, payment for the independent dispute resolution process shall be the responsibility of the physician or hospital.

(c) A hardship shall exist if the household income of the patient who is not an insured is below 250 percent of the Federal poverty level, as determined annually by the Secretary of Health and Human Services.

(d) Any payments due to an IDRE under this section shall be made to the IDRE within 30 calendar days from receipt of the IDRE's written determination and invoice.

N.Y. Comp. Codes R. & Regs. Tit. 23 § 400.10

Adopted New York State Register June 3, 2015/Volume XXXVII, Issue 22, eff. 6/3/2015

Amended New York State Register July 14, 2021/Volume XLIII, Issue 28, eff. 8/13/2021