N.Y. Comp. Codes R. & Regs. tit. 23 § 400.3

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

Section 400.3 - Independent dispute resolution entity (IDRE) certification requirements

(a) An entity applying to be an IDRE certified to perform reviews regarding bills for emergency services, including inpatient services that follow an emergency room visit, and surprise bills pursuant to Financial Services Law Article 6 shall submit to the superintendent:

(1) a description of the proposed IDRE's organizational structure and capability to operate a statewide IDRE, including:

(i) a certificate of incorporation, articles of organization and bylaws or operating agreement of the proposed IDRE and, as applicable, those of the proposed IDRE's holding company or parent company;

(ii) the proposed IDRE's organizational chart;

(iii) identification of management staff and a description of such management staff's responsibilities;

(iv) the name and credentials of a medical director appointed by the proposed IDRE, who is a physician in possession of a current and valid non-restricted license to practice medicine in New York;

(v) the names and biographies of all controlling employees, officers, and executives of the proposed IDRE; and information concerning the governing board of the proposed IDRE, including roles and responsibilities, identification of the board members and a description of their qualifications;

(2) a sworn statement, as described in section 400.4(b) of this Part, signed by the chief executive officer of the proposed IDRE regarding conflicts of interest;

(3) the names of all corporations and organizations that control, are controlled by, or under common control with the proposed IDRE, and the nature and extent of any such control;

(4) the proposed IDRE's policies and procedures governing all aspects of the dispute resolution process, including at a minimum:

(i) a description and a chart or diagram of the sequence of steps through which a dispute will move from receipt through notification to the health care plan, physician, superintendent, and provider, insured, or patient, if applicable, regarding the dispute determination;

(ii) procedures for ensuring that no prohibited material familial, financial or professional affiliation exists with respect to the reviewer and reviewing physician assigned to the dispute. The procedures shall include, for each reviewer and reviewing physician assigned to review a dispute, a requirement for a signed attestation affirming, under penalty of perjury, that no prohibited material familial, financial or professional affiliation exists with respect to the reviewer's or reviewing physician's participation in the review of the dispute;

(iii) procedures to ensure that the dispute is reviewed by a neutral and impartial reviewer with training and experience in healthcare billing, reimbursement, and usual and customary charges and determinations are made in consultation with a neutral and impartial licensed reviewing physician in active practice in the same or similar specialty as the physician providing the service that is subject to the dispute, who is also, to the extent practicable, licensed in New York;

(iv) procedures for the reporting and review of reviewer's and reviewing physician's conflicts of interest and for assigning or reassigning a dispute resolution where a conflict or potential conflict is identified;

(v) procedures to ensure that reviews are conducted within the time frames specified in section 400.8 of this Part and any required notices are provided in a timely manner;

(vi) procedures to ensure the confidentiality of medical and treatment records and review materials; and

(vii) procedures to ensure adherence to the requirements of this Part by any contractor, subcontractor, agent or employee affiliated by contract or otherwise with the proposed IDRE;

(5) a description of the reviewer and reviewing physician network, including:

(i) an assessment of the proposed IDRE's ability to provide review services statewide;

(ii) a description of the qualifications of the reviewers and reviewing physicians retained to review payment disputes, including current and past employment history and practice affiliations, as applicable;

(iii) a description of the procedures employed to ensure that reviewers and reviewing physicians reviewing payment disputes are:

(a) appropriately licensed, registered or certified, if applicable;

(b) trained in the principles, procedures and standards of the proposed IDRE;

(c) knowledgeable about the health care service which is the subject of the payment dispute under review; and

(d) with respect to reviewers, trained and experienced in health care billing, reimbursement and usual and customary charges;

(iv) a description of the methods of recruiting and selecting neutral and impartial reviewers and reviewing physicians and matching such reviewers and reviewing physicians to specific cases;

(v) the number of reviewers and reviewing physicians retained by the proposed IDRE, and a description of the areas of expertise available from reviewing physicians and the types of cases reviewing physicians are qualified to review;

(vi) the proposed IDRE's quality assurance program, which shall include written descriptions, to be provided to all individuals involved in such program; the organizational arrangements and ongoing procedures for the identification, evaluation, resolution and follow-up of potential and actual problems in payment dispute reviews performed by the reviewer and reviewing physician; and the maintenance of program standards pursuant to this subdivision; and

(vii) written procedures documenting that:

(a) appropriate personnel are reasonably accessible not less than 40 hours per week during normal business hours to discuss the dispute resolution process and to allow response to telephone requests;

(b) a response to an accepted or recorded message shall be made not less than one business day after the date on which the call was received; and

(viii) documentation of accreditation by a nationally recognized private accrediting organization, if accreditation is available;

(6) a list of its fees, which shall reflect the total amount that will be charged by the proposed IDRE for reviews, inclusive of indirect costs, administrative fees and incidental expenses, and a description of the methodology used to calculate the fees. The description shall include the pro-rated fee that will be charged when a good faith negotiation directed by the proposed 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 description also shall include an application processing fee when the dispute is determined by the proposed IDRE to be ineligible for review. The description shall provide a waiver of the fee for disputes submitted by patients when the fee would pose a financial hardship to the patient;

(7) a description of the proposed IDRE's ability to accept requests for reviews, provide requisite notifications, screen for material affiliations, respond to calls from the State and meet other requirements during normal business hours; and

(8) such other information as the superintendent may require.

(b) An IDRE may not charge any fee unless it has been filed with the superintendent and the superintendent has determined that the fee is reasonable.

N.Y. Comp. Codes R. & Regs. Tit. 23 § 400.3

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