N.Y.
Financial Services Law Section 607
Dispute resolution for surprise bills
(a)
Surprise bill involving an insured.(1)
For a surprise bill involving an insured, the health care plan shall pay the non-participating provider in accordance with paragraphs two and three of this subsection.(2)
The non-participating provider may bill the health care plan for the health care services rendered, and the health care plan shall pay the non-participating provider the billed amount or attempt to negotiate reimbursement with the non-participating provider.(3)
If the health care plan’s attempts to negotiate reimbursement for health care services provided by a non-participating provider does not result in a resolution of the payment dispute between the non-participating provider and the health care plan, the health care plan shall pay the non-participating provider an amount the health care plan determines is reasonable for the health care services rendered, except for the insured’s copayment, coinsurance or deductible, 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, and shall ensure that the insured shall incur no greater out-of-pocket costs for the surprise bill than the insured would have incurred with a participating provider.(4)
Either the health care plan or the non-participating provider may submit the dispute regarding the surprise bill for review to an independent dispute resolution entity, provided however, the health care plan may not submit the dispute unless it has complied with the requirements of paragraphs one, two and three of this subsection.(5)
The independent dispute resolution entity shall make a determination within thirty business days of receipt of the dispute for review.(6)
When determining a reasonable fee for the services rendered, the independent dispute resolution entity shall select either the health care plan’s payment or the non-participating provider’s fee. An 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)
Surprise bill received by a patient who is not an insured.(1)
A patient who is not an insured and who receives a surprise bill may submit a dispute regarding the surprise bill for review to an independent dispute resolution entity.(2)
The independent dispute resolution entity shall determine a reasonable fee for the services rendered based upon the conditions and factors set forth in § 604 (Criteria for determining a reasonable fee)section six hundred four of this article.(3)
A patient shall not be required to pay the physician’s fee to be eligible to submit the dispute for review to the independent dispute resolution entity.(c)
The determination of an independent dispute resolution entity shall be binding on the patient, provider and health care plan, and shall be admissible in any court proceeding between the patient or insured, provider or health care plan, or in any administrative proceeding between this state and the provider.
Source:
Section 607 — Dispute resolution for surprise bills, https://www.nysenate.gov/legislation/laws/FIS/607 (updated Apr. 22, 2022; accessed Oct. 26, 2024).
