§ 605 — Dispute resolution for emergency services

§ 605. Dispute resolution for emergency services. (a) Emergency\nservices for an insured. * (1) When a health care plan receives a bill\nfor emergency services from a non-participating provider, including a\nbill for inpatient services which follow an emergency room visit, the\nhealth care plan shall pay an amount that it determines is reasonable\nfor the emergency services, including inpatient services which follow an\nemergency room visit, rendered by the non-participating provider, in\naccordance with section three thousand two hundred twenty-four-a of the\ninsurance law, except for the insured's co-payment, coinsurance or\ndeductible, if any, and shall ensure that the insured shall incur no\ngreater out-of-pocket costs for the emergency services, including\ninpatient services which follow an emergency room visit, than the\ninsured would have incurred with a participating provider. The\nnon-participating provider may bill the health care plan for the\nservices rendered. Upon receipt of the bill, the health care plan shall\npay the non-participating provider the amount prescribed by this section\nand any subsequent amount determined to be owed to the provider in\nrelation to the emergency services provided, including inpatient\nservices which follow an emergency room visit.\n * NB Effective until after the superintendent of financial services\nand the commissioner of health have promulgated regulations\n * (1) When a health care plan receives a bill for emergency services\nfrom a non-participating provider, including a bill for inpatient\nservices which follow an emergency room visit, or a bill for services\nfrom a mobile crisis intervention services provider licensed, certified,\nor designated by the office of mental health or the office of addiction\nservices and supports, the health care plan shall pay an amount that it\ndetermines is reasonable for the emergency services, including inpatient\nservices which follow an emergency room visit or for the mobile crisis\nintervention services, rendered by the non-participating provider, in\naccordance with section three thousand two hundred twenty-four-a of the\ninsurance law, except for the insured's co-payment, coinsurance or\ndeductible, if any, and shall ensure that the insured shall incur no\ngreater out-of-pocket costs for the emergency services, including\ninpatient services which follow an emergency room visit or for the\nmobile crisis intervention services, than the insured would have\nincurred with a participating provider. The non-participating provider\nmay bill the health care plan for the services rendered. Upon receipt of\nthe bill, the health care plan shall pay the non-participating provider\nthe amount prescribed by this section and any subsequent amount\ndetermined to be owed to the provider in relation to the emergency\nservices provided, including inpatient services which follow an\nemergency room visit or for the mobile crisis intervention services.\n * NB Effective after the superintendent of financial services and the\ncommissioner of health have promulgated regulations\n * (2) A non-participating provider or a health care plan may submit a\ndispute regarding a fee or payment for emergency services, including\ninpatient services which follow an emergency room visit, for review to\nan independent dispute resolution entity.\n * NB Effective until after the superintendent of financial services\nand the commissioner of health have promulgated regulations\n * (2) A non-participating provider or a health care plan may submit a\ndispute regarding a fee or payment for emergency services, including\ninpatient services which follow an emergency room visit, or for services\nrendered by a mobile crisis intervention services provider licensed,\ncertified, or designated by the office of mental health or the office of\naddiction services and supports, for review to an independent dispute\nresolution entity.\n * NB Effective after the superintendent of financial services and the\ncommissioner of health have promulgated regulations\n (3) The independent dispute resolution entity shall make a\ndetermination within thirty business days of receipt of the dispute for\nreview.\n (4) In determining a reasonable fee for the services rendered, an\nindependent dispute resolution entity shall select either the health\ncare plan's payment or the non-participating provider's fee. The\nindependent dispute resolution entity shall determine which amount to\nselect based upon the conditions and factors set forth in section six\nhundred four of this article. If an independent dispute resolution\nentity determines, based on the health care plan's payment and the\nnon-participating provider's fee, that a settlement between the health\ncare plan and non-participating provider is reasonably likely, or that\nboth the health care plan's payment and the non-participating provider's\nfee represent unreasonable extremes, then the independent dispute\nresolution entity may direct both parties to attempt a good faith\nnegotiation for settlement. The health care plan and non-participating\nprovider may be granted up to ten business days for this negotiation,\nwhich shall run concurrently with the thirty business day period for\ndispute resolution.\n (b) Emergency services for a patient that is not an insured. (1) A\npatient that is not an insured or the patient's physician may submit a\ndispute regarding a fee for emergency services, including inpatient\nservices which follow an emergency room visit, for review to an\nindependent dispute resolution entity upon approval of the\nsuperintendent.\n (2) An independent dispute resolution entity shall determine a\nreasonable fee for the services based upon the same conditions and\nfactors set forth in section six hundred four of this article.\n (3) A patient that is not an insured shall not be required to pay the\nphysician's or hospital's fee in order to be eligible to submit the\ndispute for review to an independent dispute resolution entity.\n (c) The determination of an independent dispute resolution entity\nshall be binding on the health care plan, provider and patient, and\nshall be admissible in any court proceeding between the health care\nplan, provider or patient, or in any administrative proceeding between\nthis state and the provider.\n (d) For purposes of the hospital payment pursuant to subsection (a) of\nthis section, the amount the health care plan shall pay to the hospital\nshall be at least twenty-five percent greater than the amount the health\ncare plan would have paid for the claim had the hospital been in\nnetwork, based on the most recent contract between the health care plan\nand the hospital. Provided however, the amount paid by the health care\nplan pursuant to this subsection shall not prejudice either party or\npreclude either party from submitting a dispute to the dispute\nresolution entity relating to the payment to the hospital or preclude\nthe hospital from seeking additional payment from the health care plan\nprior to a decision by the dispute resolution entity. To the extent the\nprior contract between the hospital and health care plan expired greater\nthan twelve months prior to the payment of the disputed claim, the\npayment amount shall be adjusted based upon the medical consumer price\nindex. The provisions of this subsection shall only apply to the extent\nthe health care plan and hospital had previously entered into a\nparticipating provider agreement.\n