N.Y. Financial Services Law § 605: Dispute resolution for emergency services

§ 605. Dispute resolution for emergency services. (a) Emergency

services for an insured. * (1) When a health care plan receives a bill

for emergency services from a non-participating provider, including a

bill for inpatient services which follow an emergency room visit, the

health care plan shall pay an amount that it determines is reasonable

for the emergency services, including inpatient services which follow an

emergency room visit, rendered by the non-participating provider, in

accordance with section three thousand two hundred twenty-four-a of the

insurance law, except for the insured's co-payment, coinsurance or

deductible, if any, and shall ensure that the insured shall incur no

greater out-of-pocket costs for the emergency services, including

inpatient services which follow an emergency room visit, than the

insured would have incurred with a participating provider. The

non-participating provider may bill the health care plan for the

services rendered. Upon receipt of the bill, the health care plan shall

pay the non-participating provider the amount prescribed by this section

and any subsequent amount determined to be owed to the provider in

relation to the emergency services provided, including inpatient

services which follow an emergency room visit.

* NB Effective until after the superintendent of financial services

and the commissioner of health have promulgated regulations

* (1) When a health care plan receives a bill for emergency services

from a non-participating provider, including a bill for inpatient

services which follow an emergency room visit, or a bill for services

from a mobile crisis intervention services provider licensed, certified,

or designated by the office of mental health or the office of addiction

services and supports, the health care plan shall pay an amount that it

determines is reasonable for the emergency services, including inpatient

services which follow an emergency room visit or for the mobile crisis

intervention services, rendered by the non-participating provider, in

accordance with section three thousand two hundred twenty-four-a of the

insurance law, except for the insured's co-payment, coinsurance or

deductible, if any, and shall ensure that the insured shall incur no

greater out-of-pocket costs for the emergency services, including

inpatient services which follow an emergency room visit or for the

mobile crisis intervention services, than the insured would have

incurred with a participating provider. The non-participating provider

may bill the health care plan for the services rendered. Upon receipt of

the bill, the health care plan shall pay the non-participating provider

the amount prescribed by this section and any subsequent amount

determined to be owed to the provider in relation to the emergency

services provided, including inpatient services which follow an

emergency room visit or for the mobile crisis intervention services.

* NB Effective after the superintendent of financial services and the

commissioner of health have promulgated regulations

* (2) A non-participating provider or a health care plan may submit a

dispute regarding a fee or payment for emergency services, including

inpatient services which follow an emergency room visit, for review to

an independent dispute resolution entity.

* NB Effective until after the superintendent of financial services

and the commissioner of health have promulgated regulations

* (2) A non-participating provider or a health care plan may submit a

dispute regarding a fee or payment for emergency services, including

inpatient services which follow an emergency room visit, or for services

rendered by a mobile crisis intervention services provider licensed,

certified, or designated by the office of mental health or the office of

addiction services and supports, for review to an independent dispute

resolution entity.

* NB Effective after the superintendent of financial services and the

commissioner of health have promulgated regulations

* (3) The independent dispute resolution entity shall make a

determination within thirty business days of receipt of the dispute for

review.

* NB Effective until August 26, 2026

* (3) The independent dispute resolution entity shall make a

determination within forty-five business days of receipt of all

information the independent dispute resolution entity determines that it

needs to review the dispute.

* NB Effective August 26, 2026

(4) In determining a reasonable fee for the services rendered, an

independent dispute resolution entity shall select either the health

care plan's payment or the non-participating provider's fee. The

independent dispute resolution entity shall determine which amount to

select based upon the conditions and factors set forth in section six

hundred four of this article. If an independent dispute resolution

entity determines, based on the health care plan's payment and the

non-participating provider's fee, that a settlement between the health

care plan and non-participating provider is reasonably likely, or that

both the health care plan's payment and the non-participating provider's

fee represent unreasonable extremes, then the independent dispute

resolution entity may direct both parties to attempt a good faith

negotiation for settlement. The health care plan and non-participating

provider may be granted up to ten business days for this negotiation,

which shall run concurrently with the thirty business day period for

dispute resolution.

(b) Emergency services for a patient that is not an insured. (1) A

patient that is not an insured or the patient's physician may submit a

dispute regarding a fee for emergency services, including inpatient

services which follow an emergency room visit, for review to an

independent dispute resolution entity upon approval of the

superintendent.

(2) An independent dispute resolution entity shall determine a

reasonable fee for the services based upon the same conditions and

factors set forth in section six hundred four of this article.

(3) A patient that is not an insured shall not be required to pay the

physician's or hospital's fee in order to be eligible to submit the

dispute for review to an independent dispute resolution entity.

(c) The determination of an independent dispute resolution entity

shall be binding on the health care plan, provider and patient, and

shall be admissible in any court proceeding between the health care

plan, provider or patient, or in any administrative proceeding between

this state and the provider.

(d) For purposes of the hospital payment pursuant to subsection (a) of

this section, the amount the health care plan shall pay to the hospital

shall be at least twenty-five 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 contract between the health care plan

and the hospital. Provided however, the amount paid by the health care

plan pursuant to this subsection shall not prejudice either party or

preclude either party from submitting a dispute to the dispute

resolution entity relating to the payment to the hospital or preclude

the hospital from seeking additional payment from the health care plan

prior to a decision by the dispute resolution entity. To the extent the

prior contract between the hospital and health care plan expired greater

than twelve months prior to the payment of the disputed claim, the

payment amount shall be adjusted based upon the medical consumer price

index. The provisions of this subsection shall only apply to the extent

the health care plan and hospital had previously entered into a

participating provider agreement.