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This entry was published on 2015-04-10
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SECTION 602
Applicability
Financial Services Law (FIS) CHAPTER 18-A, ARTICLE 6
§ 602. Applicability. (a) This article shall not apply to health care
services, including emergency services, where physician fees are subject
to schedules or other monetary limitations under any other law,
including the workers' compensation law and article fifty-one of the
insurance law, and shall not preempt any such law.

(b)(1) With regard to emergency services billed under American medical
association current procedural terminology (CPT) codes 99281 through
99285, 99288, 99291 through 99292, 99217 through 99220, 99224 through
99226, and 99234 through 99236, the dispute resolution process
established in this article shall not apply when:

(A) the amount billed for any such CPT code meets the requirements set
forth in paragraph three of this subsection, after any applicable
co-insurance, co-payment and deductible; and

(B) the amount billed for any such CPT code does not exceed one
hundred twenty percent of the usual and customary cost for such CPT
code.

(2) The health care plan shall ensure that an insured shall not incur
any greater out-of-pocket costs for emergency services billed under a
CPT code as set forth in this subsection than the insured would have
incurred if such emergency services were provided by a participating
physician.

(3) Beginning January first, two thousand fifteen and each January
first thereafter, the superintendent shall publish on a website
maintained by the department of financial services, and provide in
writing to each health care plan, a dollar amount for which bills for
the procedure codes identified in this subsection shall be exempt from
the dispute resolution process established in this article. Such amount
shall equal the amount from the prior year, beginning with six hundred
dollars in two thousand fourteen, adjusted by the average of the annual
average inflation rates for the medical care commodities and medical
care services components of the consumer price index. In no event shall
an amount exceeding one thousand two hundred dollars for a specific CPT
code billed be exempt from the dispute resolution process established in
this article.