2023 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
involving an insured. (1) For a surprise bill involving an insured,  the
health  care plan shall pay the non-participating provider in accordance
with paragraphs two and three of this subsection.
(2) The non-participating provider may bill the health care  plan  for
the  health  care  services rendered, and the health care plan shall pay
the non-participating provider the billed amount or attempt to negotiate
reimbursement with the non-participating provider.
(3) If the health care plan's attempts to negotiate reimbursement  for
health  care  services provided by a non-participating provider does not
result  in  a  resolution   of   the   payment   dispute   between   the
non-participating  provider  and  the  health care plan, the health care
plan shall pay the non-participating provider 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, and shall ensure that the insured shall incur no  greater
out-of-pocket  costs  for  the surprise bill than the insured would have
incurred with a participating provider.
(4) Either the health care plan or the non-participating provider  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 business 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  provider'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 provider's fee, that a settlement between  the  health
care  plan  and non-participating provider is reasonably likely, or that
both the health care plan's payment and the non-participating provider'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
provider  may  be  granted up to ten business days for this negotiation,
which shall run concurrently with the thirty  business  day  period  for
dispute resolution.
(b) Surprise bill received by a patient who is not an insured.
(1)  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 shall not be required to pay the physician's fee to be
eligible to submit the dispute for review  to  the  independent  dispute
resolution entity.
(c)  The  determination  of  an  independent dispute resolution entity
shall be binding on the patient, provider  and  health  care  plan,  and
shall  be  admissible  in  any  court  proceeding between the patient or
insured,  provider  or  health  care  plan,  or  in  any  administrative
proceeding between this state and the provider.