New York Codes, Rules and Regulations › Title 11 - INSURANCE › Appendices › Appendix 17-D

Current through Register Vol. 46, No. 28, July 10, 2024
(cf. Part 68)
SCHEDULE OF RATES FOR OUTPATIENT HOSPITAL
				SERVICES
Effective 1/1/85 - 12/31/85
Room other than an operating room when used for minor surgery
				or emergency treatment:
For the medical service provided, whether by employed staff,
				attending staff or by contractual arrangement with the physician groups, the
				fee for this service is the fee as appears on line 90010 of the Schedule of
				Medical Fees.
For the hospital providing intern or resident staffing or by
				physician group contractual coverage, the total fee is the fee for physician
				services as appears on line 90010 of the Schedule of Medical Fees plus the fee
				for use of the Emergency Service Room as set forth below.
When the care is provided by an attending physician, the
				hospital fee is the Emergency Service Room fee as set forth below, with the
				physician billing separately.
Note:
The above fees include common or
				ordinary medications.
Crutches, mechanical splints and appliances Rental or sale at
				cost Plaster cast and/or splint Cost of plaster Radium and deep therapy A &
				A (authorization and arrangement) E.K.G., E.E.G., X-RAY, P.T. and laboratory
				charges Rates in Schedule of Medical Fees promulgated by the Chairman, Workers'
				Compensation Board.....................
Material supplied by the emergency room (i.e., sterile trays,
				medications, etc.) over and above those usually included with the emergency
				room visit may be charged for separately. Itemize these on the bill
				submitted.
COMMON OR ORDINARY DRUGS COVERED BY THE EMERGENCY ROOM HOSPITAL
				RATES
A study was undertaken to determine the low-cost drugs which a
				large umber of hospitals in New York State regard as fairly common or ordinary
				and for which no charges are made apart from the inclusive emergency room
				rates. A partial list of such drugs is furnished below. It is expected that the
				list will be enlarged or augmented from time to time. In the meanwhile, the
				drugs shown below or on any future similar list, or heretofore regarded as
				common or ordinary, or any additional drugs so regarded, should be considered
				as covered by the applicable emergency room rate.
No charge should be made for any drugs, whether or not listed
				hereunder, in connection with hospitalized patients.
Current List of "No Charge" Drugs and Pharmaceutical
				Supplies
Acetaminophen 325 mg tablet
Alcohol 70 percent
Alcohol swabs
Antacid (
e.g.,
Mylanta, Maalox, etc.)
Aspirin 325 mg tablet
Aromatic spirits of ammonia
Atropine 2 percent ophthalmic solution
Atropine 0.4 mg/ml
Bacitracin ointment
Castor oil
Calamine lotion
Collodion flexible
Cold cream
Clinitest tablets
Dibucaine 1 percent ointment (
e.g.,
Nupercainal)
Epinephrine injection
Ethyl Chloride spray
Gelfoam
Glycerin suppository
Hematest tablets
Hydrocortisone 1 percent ointment
Hydrogen Peroxide
Iodine
Ipecac syrup
Lidocaine 2 percent viscous (
e.g.,
Xylocaine)
Lidocaine 1 percent with/without Epinephrine
Lidocaine 2 percent with/without Epinephrine
Lidocaine 5 percent ointment
Lindane lotion (
e.g.,
Kwell)
Lubricating jelly
Magnesium Sulfate
Meperidine injection (
e.g.,
Demerol)
Merthiolate
Neomycin and Polymyxin B Sulfates w/ Hydrocortisone ophthalmic
				suspension (
e.g.
Cortisporin)
Nitroglycerin 0.4 mg s.1. tablet
Nitroglycerin 0.6 mg s.1. tablet
Peppermint Spirit
Petrolatum
Providone-Iodine solution (
e.g.,
Betadine)
Pralidoxime Chloride (
e.g.,
Protopam)
Silver Nitrate sticks
Silver Sulfadiazine cream (
e.g.,
Silvadene)
Sodium Chloride - injection
Sodium Chloride for irrigation
Sterile water for irrigation
Talcum powder
Tetanus Toxoid
Tuberculin PPD (1st and 2nd strength)
Witch Hazel
Zinc Oxide ointment
Hospital
Emergency service room
						  rateNo-Fault-effective 01/01/85-12/31/85
Western New York Region
ALLEGANY:
Cuba Memorial Hospital, Inc.
$30
Memorial Hospital of Wm. F. & Gertrude F. Jones
						  Memorial A/K/A Jones Memorial
30
CATTARAUGUS:
Olean General Hospital
37
Salamanca Hospital District Authority
28
St. Francis Hospital of Olean
30
Tri-County Memorial Hospital
30
CHAUTAUQUA:
Brooks Memorial Hospital
30
Jamestown General Hospital
48
Lake Shore Hospital, Inc.
30
Westfield Memorial Hospital, Inc.
48
Woman's Christian Association
30
ERIE:
Bertrand Chaffee Hospital
28
Buffalo Columbus Hospital
28
Buffalo General Hospital
48
Children's Hospital of Buffalo
30
Erie County Medical Center
48
Kenmore Mercy Hospital
37
Lafayette General Hospital
37
Mercy Hospital of Buffalo
28
Millard Fillmore Hospital
37
Our Lady of Victory Hospital of Lackawanna
48
Roswell Park Memorial Institute
No E.R. service
Saint Francis Hospital of Buffalo
48
Sheehan Memorial Emergency Hospital, Inc.
28
Sheridan Park Hospital, Inc.
37
Sisters of Charity Hospital
48
St. Joseph Intercommunity Hospital
37
GENESEE:
Genesee Memorial Hospital
30
St. Jerome Hospital
30
NIAGARA:
Degraff Memorial Hospital
30
Inter-Community Memorial Hospital at Newfane, Inc.
30
Lockport Memorial Hospital
48
Mount St. Mary's Hospital of Niagra Falls
37
Niagra Falls Memorial Medical Center
37
ORLEANS:
Arnold Gregory Memorial Hospital
28
Medina Memorial Hospital
30
WYOMING:
Wyoming County Community Hospital
48
CHEMUNG:
Arnot-Ogden Memorial Hospital
37
St. Joseph's Hospital of Elmira
48
LIVINGSTON:
Nicholas H. Noyes Memorial Hospital
37
MONROE:
Genesee Hospital of Rochester
48
Highland Hospital of Rochester
48
Lakeside Memorial Hospital
37
Monroe Community Hospital
No E.R. service
Park Ridge Hospital
48
Rochester General Hospital
48
St. Mary's Hospital of Rochester
48
Strong Memorial Hospital
48
ONTARIO:
Clifton Springs Hospital and Clinic
48
F.F. Thompson Hospital
30
Geneva General Hospital
37
SCHUYLER:
Schuyler Hospital
28
SENECA:
Seneca Falls Hospital
48
Waterloo Memorial Hospital, Inc. d/b/a
Taylor-Brown Memorial Hospital
48
STEUBEN:
Bethesda Hospital
28
Corning Hospital
48
Ira Davenport Memorial Hospital, Inc.
48
St. James' Mercy Hospital
30
WAYNE:
Myers Community Hospital Foundation, Inc.
37
Newark-Wayne Community Hospital, Inc.
37
YATES:
Soldiers and Sailors Memorial Hospital of Yates County,
						  Inc.
37
Central New York Region
BROOME:
Our Lady of Lourdes Memorial Hospital
37
United Health Services, Inc.
37
CAYUGA:
Auburn Memorial Hospital
30
CHENANGO:
Chenango Memorial Hospital, Inc.
37
CORTLAND:
Cortland Memorial Hospital, Inc.
37
HERKIMER:
Little Falls Hospital
30
Mohawk Valley General Hospital
28
JEFFERSON:
Carthage Area Hospital, Inc
37
Edward John Noble Hospital of Alexandria Bay
37
House of the Good Samaritan
30
Mercy Hospital of Watertown
37
LEWIS:
Lewis County General Hospital
48
MADISON:
Community Memorial Hospital, Inc.
37
Oneida City Hospital
28
ONEIDA:
Childrens Hospital and Rehabilitation Center
No E.R. service
Faxton Hospital
28
Rome Hospital and Murphy Memorial Hospital
30
St. Elizabeth Hospital
48
St. Luke's Memorial Hospital Center
30
ONONDAGA:
Community General Hospital of Greater Syracuse
48
Crouse Irvin Memorial Hospital
48
St. Joseph's Hospital Health Center
30
State University Hospital-Upstate Medical Center
48
OSWEGO:
Albert Lindley Lee Memorial Hospital
30
Oswego Hospital
30
ST. LAWRENCE:
A. Barton Hepburn Hospital
37
Canton-Potsdam Hospital
30
Clifton-Fine Hospital
28
Edward John Noble Hospital of Gouverneur
30
Massena Memorial Hospital
37
TIOGA:
Tioga General Hospital
30
TOMPKINS:
Tompkins County Hospital
30
Northeastern New York Region
ALBANY:
Albany Medical Center Hospital
48
Child's Hospital
No E.R. service
Cohoes Memorial Hospital
37
Memorial Hospital of Albany
30
St. Peter's Hospital
48
CLINTON:
Champlain Valley Physicians Hospital Medical Center
30
COLUMBIA:
Columbia Memorial Hospital
37
DELAWARE:
A. Lindsay & Olive B. O'Connor Hospital
30
Community Hospital of Stamford
30
Delaware Valley Hospital, Inc.
28
Margaretville Memorial Hospital
30
The Hospital
30
ESSEX:
Elizabethtown Community Hospital
48
Moses Ludington Hospital
48
Placid Memorial Hospital, Inc.
48
FRANKLIN:
Alice Hyde Memorial Hospital
28
General Hospital of Saranac Lake
30
FULTON
Johnstown Hospital
37
Nathan Littauer Hospital
30
GREENE:
Memorial Hospital and Nursing Home of Greene County
37
MONTGOMERY:
Amsterdam Memorial Hospital
37
St. Mary's Hospital at Amsterdam
37
OTSEGO:
Aurelia Osborn Fox Memorial Hospital
48
Mary Imogene Bassett Hospital
48
RENSSELAER:
Leonard Hospital
37
Samaritan Hospital of Troy
37
St. Mary's Hospital of Troy
37
SARATOGA:
Adirondack Regional Hospital
30
Saratoga Hospital
37
SCHENECTADY:
Bellevue Maternity Hospital, Inc.
No E.R. service
Ellis Hospital
48
St. Clare's Hospital of Schenectady
30
Sunnyview Hospital and Rehabilitation Center
No E.R. service
SCHOHARIE:
Community Hospital of Schoharie County, Inc.
48
WARREN:
Glens Falls Hospital
30
WASHINGTON:
Emma Laing Stevens Hospital
48
Mary McClellan Hospital
37
Northern Metropolitan Region
DUTCHESS:
Highland Hospital of Beacon
28
Northern Dutchess Hospital
37
St. Francis Hospital of Poughkeepsie
37
Vassar Brothers Hospital
48
ORANGE:
Arden Hill Hospital
37
Cornwall Hospital
30
E.A. Horton Memorial Hospital
48
Mercy Community Hospital of Port Jervis
28
St. Anthony Community Hospital
30
St. Luke's Hospital of Newburgh
30
Tuxedo Memorial Hospital
48
PUTNAM:
Julia Butterfield Memorial Hospital
37
Putnam Community Hospital
37
ROCKLAND:
Good Samaritan Hospital of Suffern
48
Helen Hayes Hospital
No E.R. service
Nyack Hospital
48
Summit Park Hospital-Rockland County Infirmary
No E.R. service
SULLIVAN:
Community General Hospital of Sullivan County
48
Community General Hospital of Sullivan County-G. Herman
						  Div.
37
ULSTER:
Benedictine Hospital
37
Ellenville Community Hospital
28
Kingston Hospital
30
WESTCHESTER:
Blythedale Children's Hospital
No E.R. service
Burke Rehabilitation Center
No E.R. service
Dobbs Ferry Hospital
28
Lawrence Hospital
48
Mount Vernon Hospital
37
New Rochelle Hospital Medical Center
48
New York Hospital-Cornell Medical Center Westchester
						  Division
No E.R. service
Northern Westchester Hospital
48
Peekskill Hospital
30
Phelps Memorial Hospital Association
48
St. Agnes Hospital
48
St. John's Riverside Hospital
30
St. Joseph's Hospital, Yonkers
48
St. Vincent's Hospital and Medical Center of New
						  York-Westchester Branch
No E.R. service
United Hospital
28
Westchester County Medical Center
48
White Plains Hospital Medical Center
48
Yonkers General Hospital
30
Long Island Region
NASSAU:
Central General Hospital
48
Community Hospital at Glen Cove
28
Franklin General Hospital
48
Hempstead General Hospital
48
Long Beach Memorial Hospital
28
Long Island Jewish-Hillside Medical Center (Manhasset
						  Division)
48
Lydia E. Hall Hospital
48
Massapequa General Hospital
48
Mercy Hospital of Rockville Centre
37
Mid-Island Hospital
37
Nassau County Medical Center-East Meadow Division
48
Nassau Hospital (Winthrop-University Hospital)
37
North Shore University Hospital
48
South Nassau Communities Hospital
30
St. Francis Hospital of Roslyn
48
Syosset Community Hospital
48
Winthrop-University Hospital (Nassau Hospital)
37
SUFFOLK:
Brookhaven Memorial Hospital
48
Brunswick Hospital Center, Inc.
48
Central Suffolk Hospital Association
28
Eastern Long Island Hospital
28
Good Samaritan Hospital of West Islip
37
Huntington Hospital
30
John T. Mather Memorial Hospital of Port Jefferson, New
						  York, Inc.
48
Smithtown General Hospital
48
Southampton Hospital
30
Southside Hospital
48
St. Charles' Hospital
37
St. John's Episcopal Hospital, Smithtown
37
University Hospital of Stony Brook
48
NEW YORK CITY:
Astoria General Hospital
30
Baptist Medical Center of New York
28
Bayley Seton Hospital
48
Beth Israel Medical Center
48
Booth Memorial Medical Center
48
Boulevard Hospital
28
Bronx-Lebanon Hospital Center
37
Brookdale Hospital Medical Center
48
Brooklyn/Caledonia Hospital
48
Cabrini Health Care Center
48
Calvary Hospital
No E.R. service
Catholic Medical Center
48
Community Hospital of Brooklyn, Inc.
37
Deepdale General Hospital
30
Doctors Hospital, Inc.
48
Doctors Hospital of Staten Island
37
Flatbush General Hospital
28
Flushing Hospital and Medical Center
30
Hip Hospital, Inc. (La Guardia)
48
Hospital for Joint Diseases and Medical Center Orthopedic
						  Institute
No E.R. service
Hospital for Special Surgery
No E.R. service
Institute of Rehab Medicine NY University
No E.R. service
Interfaith Medical Center
48
Jamaica Hospital
48
Joint Diseases North General Hospital
48
Kings Highway Hospital
30
Kingsbrook Jewish Medical Center
48
Lenox Hill Hospital
48
Long Island College Hospital
48
Long Island Jewish-Hillside Medical Center
48
Lutheran Medical Center
48
Maimonides Medical Center
48
Manhattan Eye, Ear and Throat Hospital
30
Medical Arts Center Hospital
30
Memorial Hospital for Cancer and Allied Diseases
No E.R. service
Methodist Hospital of Brooklyn
48
Misericordia Hospital Medical Center (Our Lady of Mercy
						  Medical Center)
37
Monteflore Hospital and Medical Center
48
Mount Sinai Hospital
48
New York Eye and Ear Infirmary
No E.R. service
New York Hospital and Payne Whitney Psychiatric
						  Clinic
48
New York Infirmary-Beekman Downtown Hospital
48
New York University Medical Center
48
Osteopathic/Hillcrest Hospital (St. Joseph's Hospital
						  Div. of CMC)
48
Our Lady of Mercy Medical Center
37
Parkway Hospital
48
Parsons Hospital
37
Pelham Bay General Hospital
48
Peninsula Hospital Center
48
Physicians Hospital
28
Presbyterian Hospital in the City of New York
48
Prospect Hospital
28
Richmond Memorial Hospital and Health Center
48
Rockefeller University Hospital
No E.R. service
St. Barnabas Hospital
48
St. Clare's Hospital and Health Center
48
St. John's Episcopal Hospital
37
St. Joseph's Hospital Division of CMC
48
St. Luke's-Roosevelt Hospital Center
48
St. Mary's Hospital of Brooklyn
48
St. Vincent's Hospital and Medical Center of New
						  York
48
St. Vincent's Medical Center of Richmond
48
State University Hospital-Downstate Medical Center
No E.R. service
Staten Island Hospital
48
Union Hospital of The Bronx
28
Victory Memorial Hospital
37
Westchester Square Hospital
48
Wyckoff Heights Hospital
37
HEALTH AND HOSPITAL CORPORATION:
Bellevue Hospital Center
48
Bronx Municipal Hospital Center
37
City Hospital Center at Elmhurst
28
Coler Memorial Hospital and Home
No E.R. service
Coney Island Hospital
37
Cumberland Hospital
30
Goldwater Memorial Hospital
No E.R. service
Harlem Hospital Center
48
Kings County Hospital Center
30
Lincoln Medical and Mental Health Center
48
Metropolitan Hospital Center
48
North Central Bronx Hospital
48
Queens Hospital Center
37
Woodhull Medical and Mental Health Center
48