N.Y. Comp. Codes R. & Regs. tit. 23 § 400.6

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

Section 400.6 - Responsibilities of physicians, hospitals, and non-participating referred health care providers for disputes regarding emergency services and surprise bills

(a)

(1) If a non-participating physician or non-participating referred health care provider bills a patient for a surprise bill, the non-participating physician or non-participating referred health care provider shall provide a claim form to the patient and an assignment of benefits form in a form prescribed by the superintendent.

(2) If a non-participating physician or a non-participating hospital bills a patient for emergency services, including inpatient services that follow an emergency room visit, the non-participating physician or nonparticipating hospital shall provide a claim form and an assignment of benefits form to the patient.

(b)

(1) If an insured assigns benefits for a surprise bill in writing to a non-participating physician or nonparticipating referred health care provider that knows the insured is insured under a health care plan, the nonparticipating physician or non-participating referred health care provider shall not bill or seek payment from the insured except for any applicable copayment, coinsurance or deductible that would be owed if the insured utilized a participating physician.

(2) If an insured assigns benefits for emergency services, including inpatient services that follow an emergency room visit, to a non-participating physician or non-participating hospital that knows the insured is insured under a health care plan, the non-participating physician or non-participating hospital shall not bill or seek payment from the insured except for any applicable copayment, coinsurance or deductible that would be owed if the insured utilized a participating physician or hospital.

(c) If a health care plan attempts to negotiate reimbursement with a non-participating physician, nonparticipating hospital that had not previously entered into a participating provider agreement with the health care plan, or non-participating referred health care provider, the non-participating physician, non-participating hospital, or non-participating referred health care provider shall have at least seven business days to respond to the health care plan's offer, except when the seven business days would exceed the timeframes established in Insurance Law section 3224-a for a health care plan to pay a claim.

(d) In disputes involving emergency services, including inpatient services that follow an emergency room visit, rendered by a non-participating hospital that had previously entered into a participating provider agreement with a health care plan, if the non-participating hospital believes that the initial payment amount paid pursuant to subparagraph (ii) of paragraph (1) of subdivision (a) of section 400.5 of this Part by the health care plan is not reasonable, the non-participating hospital may submit a dispute to the superintendent for review by an IDRE, as provided in section 400.7 of this Part, and propose an amount it deems reasonable, provided that the nonparticipating hospital:

(1) notifies the health care plan of its intent to submit the dispute to the superintendent, together with the non-participating hospital's best and final offer and an explanation of the calculation, including the aggregation or any other methodology used by the non-participating hospital to develop its best and final offer;

(2) provides the health care plan with 15 business days to respond to the non-participating hospital with the health care plan's best and final offer before submitting the dispute to the superintendent;

(3) includes its best and final offer and the health care plan's best and final offer, if any, in its submission of the dispute to the superintendent; and

(4) notifies the health care plan of the dispute at the time of the submission to the superintendent.

(e) If the IDRE directs the non-participating physician, non-participating hospital, or non-participating referred health care provider to engage in negotiations with the health care plan, the non-participating physician, non-participating hospital, or non-participating referred health care provider shall do so in good faith. If a settlement is reached, the non-participating physician, non-participating hospital, or nonparticipating referred health care provider shall notify the IDRE within two business days of the settlement. If a settlement is not reached or the parties agree that a settlement is not attainable, the non-participating physician, non-participating hospital, or non-participating referred health care provider shall promptly notify the IDRE no later than the end of the time period granted by the IDRE for negotiation.

(f) A non-participating physician, non-participating hospital, or non-participating referred health care provider shall respond to all inquiries from the superintendent relating to the dispute resolution process within three business days.

(g) If the IDRE issues a determination in favor of the health care plan in a dispute involving emergency services provided by a non-participating hospital that had previously entered into a participating provider agreement with the health care plan, including inpatient services that follow an emergency room visit, the nonparticipating hospital shall pay any amount owed to the health care plan within 30 days from the date of the determination.

N.Y. Comp. Codes R. & Regs. Tit. 23 § 400.6

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