§ 607 — Dispute resolution for surprise bills

§ 607. Dispute resolution for surprise bills. (a) Surprise bill\ninvolving an insured. (1) For a surprise bill involving an insured, the\nhealth care plan shall pay the non-participating provider in accordance\nwith paragraphs two and three of this subsection.\n (2) The non-participating provider may bill the health care plan for\nthe health care services rendered, and the health care plan shall pay\nthe non-participating provider the billed amount or attempt to negotiate\nreimbursement with the non-participating provider.\n (3) If the health care plan's attempts to negotiate reimbursement for\nhealth care services provided by a non-participating provider does not\nresult in a resolution of the payment dispute between the\nnon-participating provider and the health care plan, the health care\nplan shall pay the non-participating provider an amount the health care\nplan determines is reasonable for the health care services rendered,\nexcept for the insured's copayment, coinsurance or deductible, in\naccordance with section three thousand two hundred twenty-four-a of the\ninsurance law, and shall ensure that the insured shall incur no greater\nout-of-pocket costs for the surprise bill than the insured would have\nincurred with a participating provider.\n (4) Either the health care plan or the non-participating provider may\nsubmit the dispute regarding the surprise bill for review to an\nindependent dispute resolution entity, provided however, the health care\nplan may not submit the dispute unless it has complied with the\nrequirements of paragraphs one, two and three of this subsection.\n (5) The independent dispute resolution entity shall make a\ndetermination within thirty business days of receipt of the dispute for\nreview.\n (6) When determining a reasonable fee for the services rendered, the\nindependent dispute resolution entity shall select either the health\ncare plan's payment or the non-participating provider's fee. An\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) Surprise bill received by a patient who is not an insured.\n (1) A patient who is not an insured and who receives a surprise bill\nmay submit a dispute regarding the surprise bill for review to an\nindependent dispute resolution entity.\n (2) The independent dispute resolution entity shall determine a\nreasonable fee for the services rendered based upon the conditions and\nfactors set forth in section six hundred four of this article.\n (3) A patient shall not be required to pay the physician's fee to be\neligible to submit the dispute for review to the independent dispute\nresolution entity.\n (c) The determination of an independent dispute resolution entity\nshall be binding on the patient, provider and health care plan, and\nshall be admissible in any court proceeding between the patient or\ninsured, provider or health care plan, or in any administrative\nproceeding between this state and the provider.\n