2023 New York Laws › ISC - Insurance › Article 32 - Insurance Contracts - Life, Accident and Health, Annuities › 3244 - Explanation of Benefits Forms Relating to Claims Under Certain Accident and Health Insurance Policies.

§ 3244. Explanation of benefits forms relating to claims under certain
accident  and  health  insurance  policies. (a) Every insurer, including
health maintenance organizations operating under article  forty-four  of
the  public  health  law  or article forty-three of this chapter and any
other corporation operating under article forty-three of  this  chapter,
is  required to provide the insured or subscriber with an explanation of
benefits form in response to the filing of any claim under a  policy  or
certificate  providing  coverage for hospital, medical or pharmaceutical
expenses, including policies and  certificates  providing  nursing  home
expense or home care expense benefits.
(b)  The  explanation  of  benefits  form  must  include  at least the
following:
(1) the name of the provider of service  the  admission  or  financial
control number, if applicable;
(2) the date of service;
(3) an identification of the service for which the claim is made;
(4) the provider's charge or rate;
(5)  the  amount or percentage payable under the policy or certificate
after deductibles, co-payments, and any other reduction  of  the  amount
claimed;
(6)  a specific explanation of any denial, reduction, or other reason,
including any other third-party payor coverage, for not  providing  full
reimbursement for the amount claimed; and
(7)  a  telephone number or address where an insured or subscriber may
obtain clarification of the  explanation  of  benefits,  as  well  as  a
description  of the time limit, place and manner in which an appeal of a
denial of benefits must be brought under the policy or certificate and a
notification that failure to comply with such requirements may  lead  to
forfeiture  of  a  consumer's  right to challenge a denial or rejection,
even when a request for clarification has been made.
(c) Except on demand by the insured or subscriber, insurers, including
health maintenance organizations operating under article  forty-four  of
the  public  health  law  or article forty-three of this chapter and any
other corporation operating under article forty-three of  this  chapter,
shall  not  be  required  to  provide  the insured or subscriber with an
explanation of benefits form in any case where the service  is  provided
by  a  facility  or  provider participating in the insurer's program and
full reimbursement for the  claim,  other  than  a  co-payment  that  is
ordinarily  paid  directly  to  the  provider at the time the service is
rendered, is paid by the insurer directly to the participating  facility
or provider.
(d)  This  section  shall not apply to medicare supplemental insurance
policies or certificates or limited benefits health  insurance  policies
or certificates designed primarily to supplement medicare benefits.
(e)  The  provisions  of  this  section  requiring  an  explanation of
benefits form for pharmaceutical claims shall be satisfied by  either  a
quarterly  written  summary  of the information prescribed by subsection
(b)  of  this  section  or  by   making   such   information   available
electronically on the member portal of the insurer's, health maintenance
organization's,  or article forty-three organization's website, provided
that the member consents to receiving the information electronically.