N.Y. Comp. Codes R. & Regs. tit. 23 § 400.2

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

Section 400.2 - Definitions

As used in this Part:

(a)Active practice means actively treating persons in a state where the physician is licensed.

(b)Affiliated means controls, controlled by, or under common control.

(c)Control shall have the meaning ascribed by Insurance Law section 107(a)(16).

(d)Dispute resolution process means a process to resolve a dispute for a fee for emergency services, including inpatient services that follow an emergency room visit, or a surprise bill.

(e)Emergency condition means a medical or behavioral condition that manifests itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in:

(1) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy;

(2) serious impairment to such person's bodily functions;

(3) serious dysfunction of any bodily organ or part of such person;

(4) serious disfigurement of such person; or

(5) a condition described in 42 U.S.C. section 1395 dd (Social Security Act section 1867[e][1][A][i], [ii] or [iii]).

(f)Emergency services means, with respect to an emergency condition:

(1) a medical screening examination as required under 42 U.S.C. section 1395 dd, that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition; and

(2) within the capabilities of the staff and facilities available at the hospital, such further medical examination and treatment as are required under 42 U.S.C. section 1395 dd, to stabilize the patient.

(g)Health care plan means an insurer licensed to write accident and health insurance pursuant to Insurance Law articles 41 and 42; a corporation organized pursuant to Insurance Law article 43; a municipal cooperative health benefit plan certified pursuant to Insurance Law article 47; a health maintenance organization certified pursuant to Public Health Law article 44; or a student health plan established or maintained pursuant to Insurance Law section 1124.

(h)Health care provider means an appropriately licensed, registered or certified health care professional pursuant to Education Law title 8, or comparably licensed, registered or certified by another state, or a facility licensed or certified pursuant to Public Health Law article 5, 28, 36, 44 or 47, or Mental Hygiene Law article 19, 31 or 32, or comparably licensed by another state.

(i)Hospital means a general hospital operating pursuant to Public Health Law Article 28.

(j)Independent dispute resolution entity or IDRE means an entity certified by the superintendent pursuant to section 400.3 of this Part.

(k)Insured means a patient covered under a policy or contract with a health care plan. A patient insured by an insurer other than a health care plan is not an insured for purposes of this Part.

(l)Material familial affiliation means any relationship as a spouse, child, parent, sibling, spouse's parent, spouse's child, child's parent, child's spouse, or sibling's spouse.

(m)Material financial affiliation means any financial interest of more than five percent of total annual revenue or total annual income of an IDRE or officer, director, or managers thereof; or reviewer or reviewing physician employed or engaged thereby to conduct any independent dispute review in the dispute resolution process. The term material financial affiliation shall not include revenue received from a health care plan or physician by:

(1) an IDRE to conduct a dispute resolution pursuant to Financial Services Law article 6; or

(2) a reviewing physician for health services rendered to patients in this State.

(n)Material professional affiliation means any physician-patient relationship, any partnership or employment relationship, a shareholder or similar ownership interest in a professional corporation, or any independent contractor arrangement that constitutes a material financial affiliation with any expert or any officer or director of the IDRE.

(o)Non-participating means not having a contract with a health care plan to provide health care services to an insured.

(p)Non-participating referred health care provider means a non-participating health care provider to which an insured was referred by a participating physician without explicit written consent of the insured acknowledging that the participating physician is referring the insured to a non-participating referred health care provider and that the referral may result in costs not covered by the health care plan.

(q)Participating means having a contract with a health care plan to provide health care services to an insured.

(r)Patient means a person who receives health care services, including emergency services, in this State.

(s)Physician means an individual licensed to practice medicine pursuant to Education Law article 131 or as provided under the law of the state where the individual practices medicine.

(t)Reviewer means a person with training and experience in health care billing, reimbursement, and usual and customary charges who renders a dispute resolution determination in consultation with a reviewing physician.

(u)Reviewing physician means a licensed physician in active practice in the same or similar specialty as the physician that provided the service that is subject to the dispute resolution process who renders a dispute resolution determination in consultation with a reviewer.

(v)Surprise bill means a bill for health care services, other than emergency services, received by:

(1) An insured for services rendered by a non-participating physician at a participating hospital or ambulatory surgical center, where a participating physician is unavailable or a non-participating physician renders services without the insured's knowledge, or unforeseen medical services arise at the time the health care services are rendered; provided, however, that a surprise bill shall not mean a bill received for health care services when a participating physician is available and the insured has elected to obtain services from a non-participating physician.

(2) An insured for services rendered by a non-participating referred health care provider, where the services were referred by a participating physician to a non-participating referred health care provider without explicit written consent of the insured acknowledging that the participating physician is referring the insured to a non-participating referred health care provider and that the referral may result in costs not covered by the health care plan. A referral to a non-participating referred health care provider occurs when:

(i) health care services are performed by a non-participating health care provider in the participating physician's office or practice during the course of the same visit;

(ii) the participating physician sends a specimen taken from the patient in the participating physician's office to a non-participating laboratory or pathologist; or

(iii) for any other health care services performed by a non-participating health care provider, when referrals are required under the insured's contract.

(3) A patient who is not an insured for services rendered by a physician at a hospital or ambulatory surgical center, where the patient has not timely received all of the disclosures required pursuant to Public Health Law section 24.

(w)Usual and customary cost means the 80th percentile of all charges for the particular health care service performed by a provider in the same or similar specialty and provided in the same geographical area as reported in a benchmarking database maintained by a nonprofit organization specified by the superintendent, which is not affiliated with a health care plan.

N.Y. Comp. Codes R. & Regs. Tit. 23 § 400.2

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