§ 3244 — Explanation of benefits forms relating to claims under certain accident and health insurance policies

§ 3244. Explanation of benefits forms relating to claims under certain\naccident and health insurance policies. (a) Every insurer, including\nhealth maintenance organizations operating under article forty-four of\nthe public health law or article forty-three of this chapter and any\nother corporation operating under article forty-three of this chapter,\nis required to provide the insured or subscriber with an explanation of\nbenefits form in response to the filing of any claim under a policy or\ncertificate providing coverage for hospital, medical or pharmaceutical\nexpenses, including policies and certificates providing nursing home\nexpense or home care expense benefits.\n (b) The explanation of benefits form must include at least the\nfollowing:\n (1) the name of the provider of service the admission or financial\ncontrol number, if applicable;\n (2) the date of service;\n (3) an identification of the service for which the claim is made;\n (4) the provider's charge or rate;\n (5) the amount or percentage payable under the policy or certificate\nafter deductibles, co-payments, and any other reduction of the amount\nclaimed;\n (6) a specific explanation of any denial, reduction, or other reason,\nincluding any other third-party payor coverage, for not providing full\nreimbursement for the amount claimed; and\n (7) a telephone number or address where an insured or subscriber may\nobtain clarification of the explanation of benefits, as well as a\ndescription of the time limit, place and manner in which an appeal of a\ndenial of benefits must be brought under the policy or certificate and a\nnotification that failure to comply with such requirements may lead to\nforfeiture of a consumer's right to challenge a denial or rejection,\neven when a request for clarification has been made.\n (c) Except on demand by the insured or subscriber, insurers, including\nhealth maintenance organizations operating under article forty-four of\nthe public health law or article forty-three of this chapter and any\nother corporation operating under article forty-three of this chapter,\nshall not be required to provide the insured or subscriber with an\nexplanation of benefits form in any case where the service is provided\nby a facility or provider participating in the insurer's program and\nfull reimbursement for the claim, other than a co-payment that is\nordinarily paid directly to the provider at the time the service is\nrendered, is paid by the insurer directly to the participating facility\nor provider.\n (d) This section shall not apply to medicare supplemental insurance\npolicies or certificates or limited benefits health insurance policies\nor certificates designed primarily to supplement medicare benefits.\n (e) The provisions of this section requiring an explanation of\nbenefits form for pharmaceutical claims shall be satisfied by either a\nquarterly written summary of the information prescribed by subsection\n(b) of this section or by making such information available\nelectronically on the member portal of the insurer's, health maintenance\norganization's, or article forty-three organization's website, provided\nthat the member consents to receiving the information electronically.\n