NY Fin Serv L § 605 (2021)
2021 New York Laws FIS - Financial Services Law Article 6 - Emergency Medical Services and Surprise Bills 605 - Dispute Resolution for Emergency Services.

§  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.