Legislation

Search OpenLegislation Statutes
This entry was published on 2015-04-10
The selection dates indicate all change milestones for the entire volume, not just the location being viewed. Specifying a milestone date will retrieve the most recent version of the location before that date.
SECTION 607
Dispute resolution for surprise bills
Financial Services Law (FIS) CHAPTER 18-A, ARTICLE 6
§ 607. Dispute resolution for surprise bills. (a) Surprise bill
received by an insured who assigns benefits. (1) If an insured assigns
benefits to a non-participating physician, the health care plan shall
pay the non-participating physician in accordance with paragraphs two
and three of this subsection.

(2) The non-participating physician may bill the health care plan for
the health care services rendered, and the health care plan shall pay
the non-participating physician the billed amount or attempt to
negotiate reimbursement with the non-participating physician.

(3) If the health care plan's attempts to negotiate reimbursement for
health care services provided by a non-participating physician does not
result in a resolution of the payment dispute between the
non-participating physician and the health care plan, the health care
plan shall pay the non-participating physician 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 section three thousand two hundred twenty-four-a of the
insurance law.

(4) Either the health care plan or the non-participating physician 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 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 physician's fee. An
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 fee, that a settlement between the health
care plan and non-participating physician is reasonably likely, or that
both the health care plan's payment and the non-participating
physician'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 may be granted up to ten business days for
this negotiation, which shall run concurrently with the thirty day
period for dispute resolution.

(b) Surprise bill received by an insured who does not assign benefits
or by a patient who is not an insured. (1) An insured who does not
assign benefits in accordance with subsection (a) of this section or 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 section six hundred four of this article.

(3) A patient or insured who does not assign benefits in accordance
with subsection (a) of this section shall not be required to pay the
physician's fee to be eligible to submit the dispute for review to the
independent dispute entity.

(c) The determination of an independent dispute resolution entity
shall be binding on the patient, physician and health care plan, and
shall be admissible in any court proceeding between the patient or
insured, physician or health care plan, or in any administrative
proceeding between this state and the physician.