New York Codes, Rules and Regulations › Title 23 - FINANCIAL SERVICES › Chapter I - Regulations of the Superintendent of Financial Services › Part 400 - Independent Dispute Resolution for Emergency Services and Surprise Bills › Section 400.5 - Responsibilities of health care plans for disputes regarding emergency services and surprise bills

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Upon
				receipt of a claim for emergency services, including inpatient services that
				follow an emergency room visit, rendered by a non-participating physician or a
				non-participating hospital, a health care plan shall:
(1)
(i) pay
				the claim, within the timeframes established in Insurance Law section 3224-a,
				in an amount that it deems reasonable for the services rendered by the
				non-participating physician or non-participating hospital that had not
				previously entered into a participating provider agreement with the health care
				plan, except for the insured's co-payment, coinsurance or deductible, if any ;
				or
(ii) in disputes involving a
				non-participating hospital that had previously entered into a participating
				provider agreement with the health care plan, pay the claim, within the
				timeframes established in Insurance Law section 3224-a, in an initial amount
				that is at least 25 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 participating provider agreement between the health care plan and the
				non-participating hospital, except for the insured's co-payment, coinsurance or
				deductible, if any. In the event the prior participating provider agreement
				between the health care plan and the non-participating hospital expired more
				than 12 months prior to the payment of the disputed claim, the payment amount
				shall be adjusted based upon the annual medical consumer price index,
				compounded for each year subsequent to the year the contract terminated up
				until the year the claim is paid. If a health care plan believes that this
				initial payment amount to a non-participating hospital with which it had
				previously entered into a participating provider agreement is not reasonable,
				it may submit a dispute to the superintendent for review by an IDRE, as
				provided in section
				400.7 of this Part, and propose an
				amount it deems reasonable, provided that the health care plan:
(a) notifies the non-participating hospital
				of its intent to submit the dispute to the superintendent, together with the
				health care plan's best and final offer and an explanation of the calculation,
				including the aggregation or any other methodology used by the health care plan
				to develop its best and final offer;
(b) provides the non-participating hospital
				with 15 business days to respond to the health care plan with the
				non-participating hospital's best and final offer before submitting the dispute
				to the superintendent;
(c) includes
				its best and final offer and the non-participating hospital's best and final
				offer, if any, in its submission of the dispute to the superintendent;
				and
(d) notifies the
				non-participating hospital of the dispute at the time of the submission to the
				superintendent; and
(iii) not be precluded from attempting to
				negotiate the reimbursement amount with the non-participating physician or
				non-participating hospital within the timeframes established in Insurance Law
				section 3224-a;