NY Fin Serv L § 607 (2021)
2021 New York Laws FIS - Financial Services Law Article 6 - Emergency Medical Services and Surprise Bills 607 - Dispute Resolution for Surprise Bills.

§  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.