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This entry was published on 2020-04-17
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SECTION 605
Dispute resolution for emergency services
Financial Services Law (FIS) CHAPTER 18-A, ARTICLE 6
§ 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 physician or hospital,
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
physician or hospital, in accordance with 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
physician or hospital. If an insured assigns benefits to a
non-participating physician or hospital in relation to emergency
services, including inpatient services which follow an emergency room
visit, provided by such non-participating physician or hospital, the
non-participating physician or hospital may bill the health care plan
for the services rendered. Upon receipt of the bill, the health care
plan shall pay the non-participating physician or hospital the amount
prescribed by this section and any subsequent amount determined to be
owed to the physician or hospital in relation to the emergency services
provided, including inpatient services which follow an emergency room
visit.

(2) A non-participating physician or hospital 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.

(3) The independent dispute resolution entity shall make a
determination within thirty 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 physician's or hospital's
fee. The independent dispute resolution entity shall determine which
amount to select based upon the conditions and factors set forth in
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 physician's or hospital's fee, that a
settlement between the health care plan and non-participating physician
or hospital is reasonably likely, or that both the health care plan's
payment and the non-participating physician's or hospital'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 physician or
hospital may be granted up to ten business days for this negotiation,
which shall run concurrently with the thirty 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 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, physician or hospital and
patient, and shall be admissible in any court proceeding between the
health care plan, physician or hospital or patient, or in any
administrative proceeding between this state and the physician or
hospital.

(d) The provisions of this section shall not apply to hospitals that
had at least sixty percent of inpatient discharges annually which
consisted of medicaid, uninsured, and dual eligible individuals as
determined by the department of health in its determination of safety
net hospitals.

(e) 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.