N.Y. Insurance Law Section 3231*2
Health insurance policies and subscriber contracts

  • prohibited claims

* § 3231. Health insurance policies and subscriber contracts; prohibited claims.

(a)

For the purposes of this section the terms health care provider, practitioner, clinical laboratory services, pharmacy services, radiation therapy services, physical therapy services or x-ray or imaging services shall have the same meanings as are set forth in Public Health Law § 238 (Definitions)section two hundred thirty-eight of the public health law.

(b)

No health care provider or practitioner may demand or request any payment for clinical laboratory services, pharmacy services, radiation therapy services, physical therapy services or x-ray or imaging services furnished pursuant to a referral prohibited by subdivision one of Public Health Law § 238-A (Prohibition of financial arrangements and referrals)section two hundred thirty-eight-a of the public health law.

(c)

No insurer shall be required to pay any claim, bill or other demand or request for payment by a health care provider for clinical laboratory services, pharmacy services, radiation therapy services, physical therapy services or x-ray or imaging services furnished pursuant to a referral prohibited by subdivision one of Public Health Law § 238-A (Prohibition of financial arrangements and referrals)section two hundred thirty-eight-a of the public health law.

(d)

Every policy of accident or health insurance issued by a commercial insurer and every subscriber contract issued by a hospital service corporation, health service corporation or medical expense indemnity corporation which provides coverage for clinical laboratory services, pharmacy services, radiation therapy services, physical therapy services or x-ray or imaging services shall include a provision excluding payment of any claim, bill or other demand or request for payment for such services furnished pursuant to a referral prohibited by subdivision one of Public Health Law § 238-A (Prohibition of financial arrangements and referrals)section two hundred thirty-eight-a of the public health law.

(e)

Every insurer subject to the provisions of this section shall report to the commissioner of health any pattern of submission of claims, bills or other demands or requests for payment submitted in violation of subsection (b) of this section, within thirty days after such insurer has knowledge of such pattern.

(f)

Notwithstanding the requirements of subsections (c), (d) and (e) of this section, an insurer reimbursing for clinical laboratory services, pharmacy services, radiation therapy services, physical therapy services or x-ray or imaging services is not required to audit or investigate any claim, bill or other demand or request for payment for such items or services furnished pursuant to a referral. * NB There are 2 § 3231’s

Source: Section 3231*2 — Health insurance policies and subscriber contracts; prohibited claims, https://www.­nysenate.­gov/legislation/laws/ISC/3231*2 (updated Sep. 22, 2014; accessed Apr. 20, 2024).

3201
Approval of life, accident and health, credit unemployment, and annuity policy forms
3202
Withdrawal of approval of policy forms
3203
Individual life insurance policies
3204
Policy to contain entire contract
3205
Insurable interest in the person
3206
Policies which provide for an adjustable maximum rate of interest on policy loans
3207
Life insurance contracts by or for the benefit of minors
3208
Antedating of life insurance policies and burial agreements prohibited
3209
Life insurance, annuities and funding agreements disclosure requirements
3210
Incontestability after reinstatement
3211
Notice of premium due under life or disability insurance policy
3212
Exemption of proceeds and avails of certain insurance and annuity contracts
3213
Payment of proceeds
3214
Interest upon proceeds of life insurance policies and annuity contracts
3215
Disability benefits in connection with life insurance and annuities
3216
Individual accident and health insurance policy provisions
3217
Minimum standards in the form, content and sale of accident and health insurance
3217‑A
Disclosure of information
3217‑B
Prohibitions
3217‑C
Primary and preventive obstetric and gynecologic care
3217‑D
Grievance procedure and access to specialty care
3217‑E
Choice of health care provider
3217‑F
Prohibition on lifetime and annual limits
3217‑G
Maternal depression screenings
3217‑H
Telehealth delivery of services
3217‑I
Essential health benefits package and limit on cost-sharing
3217‑J
Utilization review determinations for medically fragile children
3218
Medicare supplemental insurance policies
3219
Annuity and pure endowment contracts and certain group annuity certificates
3220
Group life insurance policies
3221
Group or blanket accident and health insurance policies
3222
Funding agreements
3223
Group annuity contracts
3224
Standard claim forms
3224‑A
Standards for prompt, fair and equitable settlement of claims for health care and payments for health care services
3224‑B
Rules relating to the processing of health claims and overpayments to physicians
3224‑C
Coordination of benefits
3224‑D
Prescription synchronization
3225
Eligibility for health insurance in cases of exposure to DES
3226
Reinsurance contracts excepted
3227
Interest upon surrenders, policy loans and other funds
3228
Individual accident and health insurance policies
3229
Minimum benefit standards for certain long term care plans
3230
Accelerated payment of the death benefit or special surrender value under a life insurance policy
3231
Rating of individual and small group health insurance policies
3231*2
Health insurance policies and subscriber contracts
3232
Pre-existing condition provisions in health policies
3232‑A
Certification of creditable coverage
3233
Stabilization of health insurance markets and premium rates
3234
Pre-existing condition provisions in group and blanket disability policies
3234*2
Limitations on administrative services and stop-loss coverage
3235
Explanation of benefits forms relating to claims under medicare supplemental insurance policies and limited benefits health insurance pol...
3236
Public health law assessments
3237
Health insurance coverage for full-time students on medical leaves of absence
3238
Pre-authorization of health care services
3239
Wellness programs
3240
Unclaimed benefits
3240*2
Student accident and health insurance
3241
Network coverage
3242
Prescription drug coverage
3243
Discrimination because of sex or marital status in hospital, surgical or medical expense insurance
3244
Explanation of benefits forms relating to claims under certain accident and health insurance policies
3245
Liability to providers in the event of an insolvency

Accessed:
Apr. 20, 2024

Last modified:
Sep. 22, 2014

§ 3231*2’s source at nysenate​.gov

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