Source: https://dfs.ny.gov/apps_and_licensing/health_insurers/outofnetwork_law_oon_guidance
Timestamp: 2020-07-15 23:21:05
Document Index: 530054010

Matched Legal Cases: ['§ 3217', '§ 4408', '§ 3217', '§ 4408', '§ 4903', '§ 4903', '§ 4903', '§ 4903', '§ 4903', '§ 4903', '§ 4904', '§ 4904', '§ 4914', '§ 4914', '§ 4914', '§ 4914', '§ 603', '§ 24', '§ 24', '§ 24']

Out-of-Network Law (OON) Guidance | Department of Financial Services
Insurance Law §§ 3217-a(a)(17) and 4324(a)(17) and Public Health Law § 4408(r) require health plan provider directories to include a listing by specialty of the name, address and telephone number of all participating providers, including facilities, and, in addition, in the case of physicians, board certification, languages spoken and any affiliations with participating hospitals. The law requires a health plan to post the listing on its website and further requires a health plan to update its website within 15 days of the addition or termination of a provider from its network or a change in a physician's hospital affiliation. Health plans should include language in their provider contracts requiring physicians to annually report hospital affiliations and languages spoken to health plans for inclusion in the health plan's provider directory, and to report any changes in hospital affiliations within 15 days of the change. The Department of Financial Services understands that health plans may be relying on physicians to report changes in physician hospital affiliations and the Department will take that into account with respect to this requirement.
Insurance Law §§ 3217-a(a)(19)(B) and 4324(a)(20)(B) and Public Health Law § 4408(1)(t)(ii) require health plans to disclose the amount they will reimburse under their OON methodology set forth as a percentage of the usual and customary cost ("UCR"). This requirement will be satisfied if a health plan provides the approximate percentage of UCR that equates to the reimbursement under the health plan's OON methodology.
Insurance Law § 4903(b) and Public Health Law § 4903(2) require initial utilization review pre-authorization approval determinations to identify whether the services are considered in-network or out-of-network.
Initial utilization review pre-authorization denial determinations (for example medical necessity or experimental or investigational denials) do not need to identify whether the services are considered in-network or out-of-network.
Health Plans may use the following template language in their initial utilization review pre-authorization approval determinations to comply with Insurance Law § 4903(b) and Public Health Law § 4903(2) to address when the provider has not been identified; when the provider has been identified; and when the provider is out-of-network:
[provider name], the provider that you identified to provide this service, does not participate with our plan. You will be responsible for the difference between our payment and the provider's charge, in addition to your applicable out-of-network cost-sharing requirements. If you believe there is not an appropriate in-network provider to provide this service, you may request a referral or authorization to an out-of-network provider. {Drafting Note: To be used for PPO or POS coverage.}
Insurance Law § 4903(b) and Public Health Law § 4903(2) require initial utilization review pre-authorization approval determinations to identify the dollar amount a health plan will pay if the service is reimbursed under the insured's out-of-network benefits (such as PPO or POS coverage). If a health plan is unable to identify a specific dollar amount because the CPT code or codes or diagnosis code were not submitted with the request, a health plan may disclose the range of dollar amounts that it will pay for the OON service. Health plans may use the following template language in their initial utilization review pre-authorization approval determinations to address the dollar amount a health plan will pay if the service is reimbursed under the insured's out-of-network benefits (such as PPO or POS coverage):
Include language that provides "If you believe there is not an appropriate in-network provider to provide this service, you may file a utilization review appeal if you submit a written statement from your attending physician that: (1) in-network providers do not have the appropriate training and experience to meet your particular health care needs; and (2) recommends an out-of-network provider with the appropriate training and experience to meet the insured's particular health care needs who is able to perform the requested service. For this purpose, your attending physician must be a licensed, board certified or board eligible physician qualified to practice in the specialty area appropriate to treat you for the service."
State that the insured should submit a written statement from his or her attending physician that (1) in-network providers do not have the appropriate training and experience to meet the insured's particular health care needs; and (2) recommends an out-of-network provider with the appropriate training and experience to meet the insured's particular health care needs who is able to perform the requested service.
Insurance Law § 4904(a-2) and Public Health Law § 4904(1-b) require an appeal regarding a referral to an out-of-network provider to be treated as a utilization review appeal and not a grievance if the insured submits a written statement from the insured's attending physician that: (1) the in-network provider(s) does not have the appropriate training and experience to meet the insured's particular health care needs; and (2) recommends an out-of-network provider with the appropriate training and experience to meet the insured's particular health care needs who is able to perform the requested service.
A health plan, in its final adverse utilization review appeal determination of a referral to an out-of-network provider, should provide the name of at least one in-network provider with the appropriate training and experience to meet the insured's particular health care needs who is able to perform the requested service. The external appeal agent will only consider the providers listed in the final adverse utilization review appeal determination letter when making its determination about the health plan's in-network providers.
A health plan should verify that the in-network provider(s) that it identified performs the requested service or treatment, is accepting new patients, and can see the insured within a reasonable amount of time, taking the insured's condition into consideration, at the time the final adverse utilization review appeal determination letter is issued.
Insurance Law § 4914(b)(4)(D)(ii)(I) and Public Health Law § 4914(2)(d)(D)(ii)(1) require external appeal agents to consider the training and experience of the in-network provider or providers proposed by the plan, the training and experience of the out-of-network provider, the clinical standards of the plan, the information provided concerning the insured, the attending physician's recommendation, the insured's medical record, and any other pertinent information.
Insurance Law § 4914(b)(4)(D)(ii)(I) and Public Health Law § 4914(2)(d)(D)(ii)(1) provide that an external appeal agent shall overturn a health plan's denial if the agent finds that the health plan does not have a provider with the appropriate training and experience to meet the particular health care needs of the insured who is able to provide the requested service, and that the out-of-network provider has the appropriate training and experience to meet the particular health care needs of an insured, is able to provide the requested health service, and is likely to produce a more clinically beneficial outcome.
External appeal agents may need to request information from the health plan to determine whether the in-network provider is able to provide the requested health service. External appeal agents may also need to request information from the insured and the insured's attending physician to determine whether the recommended out-of-network provider is able to provide the requested health service.
Financial Services Law § 603(h) defines a "surprise bill" as a bill for health care services, other than emergency services, received by: (1) an insured for services rendered by a non-participating physician at a participating hospital or ambulatory surgical center, where a participating physician is unavailable, or a non-participating physician renders services without the insured's knowledge, or unforeseen medical services arise at the time the health care services are rendered; provided, however, that a surprise bill shall not mean a bill received for health care services when a participating physician is available and the insured has elected to obtain services from a non-participating physician; or (2) an insured for services rendered by a non-participating provider where the services were referred by a participating physician to a non-participating provider without explicit written consent of the insured acknowledging that the participating physician is referring the insured to a non-participating provider and that the referral may result in costs not covered by the health plan.
An insured's contract does not require the insured to obtain a referral before getting services and the contract covers out-of-network services. The insured has blood drawn in a participating physician's office and the specimen is sent to a non-participating laboratory without the insured's explicit written consent acknowledging that the participating physician is referring the insured to a non-participating laboratory and that the referral may result in costs not covered by the health plan. The bill would be a surprise bill and would be covered as in-network.
An insured is admitted to a participating hospital following emergency services. During that hospital stay, consultation services are provided by specialists who do not participate with the insured's health plan and either: (1) a participating physician is unavailable; or (2) a non-participating physician renders services without the insured's knowledge; or (3) or unforeseen services arise at the time services are rendered.
An insured is admitted to a participating hospital for a scheduled hospital admission. During that hospital stay, consultation services are provided by specialists who do not participate with the insured's health plan and either: (1) a participating physician is unavailable; or (2) a non-participating physician renders services without the insured's knowledge; or (3) or unforeseen services arise at the time services are rendered.
An insured's contract does not require the insured to obtain a referral before getting services. A participating physician provides the insured with a list of local laboratories and recommends that the insured make an appointment to have blood work done.
An insured's contract does not require the insured to obtain a referral before getting services. A participating provider who is not a physician (for example a speech therapist) refers the insured to a non-participating provider (for example a durable medical equipment provider).
An insured is admitted to a non-participating hospital. During that hospital stay, consultation services are provided by specialists who do not participate with the insured's health plan.
If an emergency room physician requests a consultation from a specialist to evaluate a patient in the emergency room of a hospital, and the specialist does not participate with the patient's insurance, a bill from the specialist would be considered a bill for emergency services and could be subject to the IDR process.
Would not be required to provide the patient with the name, practice name, mailing address and telephone number of any health care provider scheduled to perform anesthesiology, laboratory, pathology, radiology or assistant surgeon services because the services are not being provided in connection with care in the physician's office or coordinated or referred as part of the office visit. See Public Health Law § 24(3).
Public Health Law § 24(3) requires a physician to provide a patient or a prospective patient with the name, practice name, mailing address and telephone number of any health care provider scheduled to perform anesthesiology, laboratory, pathology, radiology or assistant surgeon services in connection with care to be provided in the physician's office for the patient or coordinated or referred by the physician for the patient at the time of referral to or coordination of services with such provider.
Public Health Law § 24(4) requires a physician, for a patient's scheduled hospital admission or scheduled outpatient hospital services, to provide a patient and the hospital with the name, practice name, mailing address and telephone number of any other physician whose services will be arranged by the physician and are scheduled at the time of the pre-admission testing, registration or admission at the time non-emergency services are scheduled.