New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter IX - Unfair Trade Practices › Part 217 - Processing Of Health Insurance Claims › Subpart 217-2 - Coordination Of Benefit Claims › Section 217-2.2 - Coordination of benefit requirements

Current through Register Vol. 46, No. 28, July 10, 2024
(a) When a health care provider submits a
				  claim to a health insurer, that submission shall suspend the time period for
				  submission of the claim to a second health insurer until such time as the
				  provider has received a remittance advice or other evidence of a benefit
				  determination, including an appeal determination, from the first health
				  insurer. After the health care provider receives a remittance advice, appeal
				  determination, or other evidence of a benefit determination from the first
				  health insurer, the health care provider shall have at least 60 days from
				  receipt of the remittance, appeal determination or other evidence of a benefit
				  determination to bill any other health insurer that has a potential payment
				  obligation. A claim submitted to the second health insurer after the 60-day
				  period shall be subject to the claims submission rules of the second health
				  insurer. Unless the health care provider is otherwise able to demonstrate, it
				  shall be presumed that the remittance advice, appeal determination, or other
				  evidence of a benefit determination was received within eight calendar days of
				  the date on the document.
(b)
(1) If a health care provider submits a claim
				  to a secondary health insurer prior to submitting the claim to the primary
				  health insurer, the secondary health insurer shall deny the claim, notify the
				  health care provider that it is secondary and notify the health care provider
				  of the identity of the primary health insurer, or, if the identity of the
				  primary health insurer is not known, provide whatever information was used to
				  make the determination that it is a secondary health insurer. The secondary
				  health insurer may provide the information by referring the health care
				  provider to the specific page of the secondary health insurer's website and
				  shall include a toll free telephone number through which the information will
				  be provided. The health care provider's submission of the claim to the primary
				  health insurer shall suspend the time period for resubmission of such claim to
				  the secondary health insurer as set forth above in subdivision (a) of this
				  section.
(2) If the information
				  provided by the secondary health insurer is not sufficient to determine the
				  identity of the primary health insurer, the health care provider shall have 60
				  days from the notice that other coverage may exist to make a reasonable effort
				  to confirm if other coverage does exist. A "reasonable effort" shall include at
				  least an attempt by the health care provider to contact the patient.
(3) If the health care provider is unable to
				  confirm other coverage within 60 days as provided in paragraph (2) of this
				  subdivision, the secondary health insurer shall process the claim in accordance
				  with the provisions in the health insurance policy, provided that the health
				  care provider resubmits the claim to the secondary health insurer, with copies
				  of the documents to support the health care provider's efforts to confirm other
				  coverage, within 30 days of the determination that other coverage could not be
				  confirmed despite reasonable efforts.