N.Y. Insurance Law Section 3244
Explanation of benefits forms relating to claims under certain accident and health insurance policies


(a)

Every insurer, including health maintenance organizations operating under article forty-four of the public health law or article forty-three of this chapter and any other corporation operating under article 43 (Non-profit Medical and Dental Indemnity, or Health and Hospital Service Corporations)article forty-three of this chapter, is required to provide the insured or subscriber with an explanation of benefits form in response to the filing of any claim under a policy or certificate providing coverage for hospital, medical or pharmaceutical expenses, including policies and certificates providing nursing home expense or home care expense benefits.

(b)

The explanation of benefits form must include at least the following:

(1)

the name of the provider of service the admission or financial control number, if applicable;

(2)

the date of service;

(3)

an identification of the service for which the claim is made;

(4)

the provider’s charge or rate;

(5)

the amount or percentage payable under the policy or certificate after deductibles, co-payments, and any other reduction of the amount claimed;

(6)

a specific explanation of any denial, reduction, or other reason, including any other third-party payor coverage, for not providing full reimbursement for the amount claimed; and

(7)

a telephone number or address where an insured or subscriber may obtain clarification of the explanation of benefits, as well as a description of the time limit, place and manner in which an appeal of a denial of benefits must be brought under the policy or certificate and a notification that failure to comply with such requirements may lead to forfeiture of a consumer’s right to challenge a denial or rejection, even when a request for clarification has been made.

(c)

Except on demand by the insured or subscriber, insurers, including health maintenance organizations operating under article forty-four of the public health law or article forty-three of this chapter and any other corporation operating under article 43 (Non-profit Medical and Dental Indemnity, or Health and Hospital Service Corporations)article forty-three of this chapter, shall not be required to provide the insured or subscriber with an explanation of benefits form in any case where the service is provided by a facility or provider participating in the insurer’s program and full reimbursement for the claim, other than a co-payment that is ordinarily paid directly to the provider at the time the service is rendered, is paid by the insurer directly to the participating facility or provider.

(d)

This section shall not apply to medicare supplemental insurance policies or certificates or limited benefits health insurance policies or certificates designed primarily to supplement medicare benefits.

(e)

The provisions of this section requiring an explanation of benefits form for pharmaceutical claims shall be satisfied by either a quarterly written summary of the information prescribed by subsection (b) of this section or by making such information available electronically on the member portal of the insurer’s, health maintenance organization’s, or article forty-three organization’s website, provided that the member consents to receiving the information electronically.

Source: Section 3244 — Explanation of benefits forms relating to claims under certain accident and health insurance policies, https://www.­nysenate.­gov/legislation/laws/ISC/3244 (updated Mar. 25, 2022; accessed Jun. 22, 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:
Jun. 22, 2024

Last modified:
Mar. 25, 2022

§ 3244’s source at nysenate​.gov

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