N.Y.
Financial Services Law Section 605
Dispute resolution for emergency services
(a)
Emergency services for an insured. * (1) When a health care plan receives a bill for emergency services from a non-participating provider, including a bill for inpatient services which follow an emergency room visit, the health care plan shall pay an amount that it determines is reasonable for the emergency services, including inpatient services which follow an emergency room visit, rendered by the non-participating provider, in accordance with Insurance Law § 3224-A (Standards for prompt, fair and equitable settlement of claims for health care and payments for health care services)section three thousand two hundred twenty-four-a of the insurance law, except for the insured’s co-payment, coinsurance or deductible, if any, and shall ensure that the insured shall incur no greater out-of-pocket costs for the emergency services, including inpatient services which follow an emergency room visit, than the insured would have incurred with a participating provider. The non-participating provider may bill the health care plan for the services rendered. Upon receipt of the bill, the health care plan shall pay the non-participating provider the amount prescribed by this section and any subsequent amount determined to be owed to the provider in relation to the emergency services provided, including inpatient services which follow an emergency room visit. * NB Effective until January 1, 2025 and shall remain in effect until after the superintendent of financial services and the commissioner of health have promulgated regulations * (1) When a health care plan receives a bill for emergency services from a non-participating provider, including a bill for inpatient services which follow an emergency room visit, or a bill for services from a mobile crisis intervention services provider licensed, certified, or designated by the office of mental health or the office of addiction services and supports, the health care plan shall pay an amount that it determines is reasonable for the emergency services, including inpatient services which follow an emergency room visit or for the mobile crisis intervention services, rendered by the non-participating provider, in accordance with Insurance Law § 3224-A (Standards for prompt, fair and equitable settlement of claims for health care and payments for health care services)section three thousand two hundred twenty-four-a of the insurance law, except for the insured’s co-payment, coinsurance or deductible, if any, and shall ensure that the insured shall incur no greater out-of-pocket costs for the emergency services, including inpatient services which follow an emergency room visit or for the mobile crisis intervention services, than the insured would have incurred with a participating provider. The non-participating provider may bill the health care plan for the services rendered. Upon receipt of the bill, the health care plan shall pay the non-participating provider the amount prescribed by this section and any subsequent amount determined to be owed to the provider in relation to the emergency services provided, including inpatient services which follow an emergency room visit or for the mobile crisis intervention services. * NB Effective January 1, 2025 but shall not take effect until after the superintendent of financial services and the commissioner of health have promulgated regulations * (2) A non-participating provider or a health care plan may submit a dispute regarding a fee or payment for emergency services, including inpatient services which follow an emergency room visit, for review to an independent dispute resolution entity. * NB Effective until January 1, 2025 and shall remain in effect until after the superintendent of financial services and the commissioner of health have promulgated regulations * (2) A non-participating provider or a health care plan may submit a dispute regarding a fee or payment for emergency services, including inpatient services which follow an emergency room visit, or for services rendered by a mobile crisis intervention services provider licensed, certified, or designated by the office of mental health or the office of addiction services and supports, for review to an independent dispute resolution entity. * NB Effective January 1, 2025 but shall not take effect until after the superintendent of financial services and the commissioner of health have promulgated regulations (3) The independent dispute resolution entity shall make a determination within thirty business days of receipt of the dispute for review.(4)
In determining a reasonable fee for the services rendered, an independent dispute resolution entity shall select either the health care plan’s payment or the non-participating provider’s fee. The independent dispute resolution entity shall determine which amount to select based upon the conditions and factors set forth in § 604 (Criteria for determining a reasonable fee)section six hundred four of this article. If an independent dispute resolution entity determines, based on the health care plan’s payment and the non-participating provider’s fee, that a settlement between the health care plan and non-participating provider is reasonably likely, or that both the health care plan’s payment and the non-participating provider’s fee represent unreasonable extremes, then the independent dispute resolution entity may direct both parties to attempt a good faith negotiation for settlement. The health care plan and non-participating provider may be granted up to ten business days for this negotiation, which shall run concurrently with the thirty business day period for dispute resolution.(b)
Emergency services for a patient that is not an insured.(1)
A patient that is not an insured or the patient’s physician may submit a dispute regarding a fee for emergency services, including inpatient services which follow an emergency room visit, for review to an independent dispute resolution entity upon approval of the superintendent.(2)
An independent dispute resolution entity shall determine a reasonable fee for the services based upon the same conditions and factors set forth in § 604 (Criteria for determining a reasonable fee)section six hundred four of this article.(3)
A patient that is not an insured shall not be required to pay the physician’s or hospital’s fee in order to be eligible to submit the dispute for review to an independent dispute resolution entity.(c)
The determination of an independent dispute resolution entity shall be binding on the health care plan, provider and patient, and shall be admissible in any court proceeding between the health care plan, provider or patient, or in any administrative proceeding between this state and the provider.(d)
For purposes of the hospital payment pursuant to subsection (a) of this section, the amount the health care plan shall pay to the hospital shall be at least twenty-five percent greater than the amount the health care plan would have paid for the claim had the hospital been in network, based on the most recent contract between the health care plan and the hospital. Provided however, the amount paid by the health care plan pursuant to this subsection shall not prejudice either party or preclude either party from submitting a dispute to the dispute resolution entity relating to the payment to the hospital or preclude the hospital from seeking additional payment from the health care plan prior to a decision by the dispute resolution entity. To the extent the prior contract between the hospital and health care plan expired greater than twelve months prior to the payment of the disputed claim, the payment amount shall be adjusted based upon the medical consumer price index. The provisions of this subsection shall only apply to the extent the health care plan and hospital had previously entered into a participating provider agreement.
Source:
Section 605 — Dispute resolution for emergency services, https://www.nysenate.gov/legislation/laws/FIS/605 (updated May 12, 2023; accessed Apr. 20, 2024).
