2023 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 provider, 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  provider,  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   provider.   The
non-participating  provider  may  bill  the  health  care  plan  for the
services rendered. Upon receipt of the bill, the health care plan  shall
pay the non-participating provider the amount prescribed by this section
and  any  subsequent  amount  determined  to  be owed to the provider in
relation  to  the  emergency  services  provided,  including   inpatient
services which follow an emergency room visit.
* NB  Effective until January 1, 2025 and shall remain in effect until
after the superintendent of financial services and the  commissioner  of
health have promulgated regulations
* (1)  When  a health care plan receives a bill for emergency services
from a  non-participating  provider,  including  a  bill  for  inpatient
services  which  follow  an emergency room visit, or a bill for services
from a mobile crisis intervention services provider licensed, certified,
or designated by the office of mental health or the office of  addiction
services  and supports, 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 or for the  mobile  crisis
intervention  services,  rendered  by the non-participating provider, 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  or  for  the
mobile  crisis  intervention  services,  than  the  insured  would  have
incurred with a participating provider. The  non-participating  provider
may bill the health care plan for the services rendered. Upon receipt of
the  bill, the health care plan shall pay the non-participating provider
the  amount  prescribed  by  this  section  and  any  subsequent  amount
determined  to  be  owed  to  the  provider in relation to the emergency
services  provided,  including  inpatient  services  which   follow   an
emergency room visit or for the mobile crisis intervention services.
* NB  Effective  January 1, 2025 but shall not take effect until after
the superintendent of financial services and the commissioner of  health
have promulgated regulations
* (2)  A non-participating provider 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.
* NB Effective until January 1, 2025 and shall remain in effect  until
after  the  superintendent of financial services and the commissioner of
health have promulgated regulations
* (2) A non-participating provider 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, or for services
rendered by a mobile crisis  intervention  services  provider  licensed,

certified, or designated by the office of mental health or the office of
addiction  services  and  supports, for review to an independent dispute
resolution entity.
* NB  Effective  January 1, 2025 but shall not take effect until after
the superintendent of financial services and the commissioner of  health
have promulgated regulations
(3)   The   independent   dispute   resolution  entity  shall  make  a
determination within thirty business 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  provider'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 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)  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, provider and patient, and
shall be admissible in any court  proceeding  between  the  health  care
plan,  provider  or patient, or in any administrative proceeding between
this state and the provider.
(d) 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.