N.Y. Financial Services Law § 607: Dispute resolution for surprise bills

§ 607. Dispute resolution for surprise bills. (a) Surprise bill

involving an insured. (1) For a surprise bill involving an insured, the

health care plan shall pay the non-participating provider in accordance

with paragraphs two and three of this subsection.

(2) The non-participating provider may bill the health care plan for

the health care services rendered, and the health care plan shall pay

the non-participating provider the billed amount or attempt to negotiate

reimbursement with the non-participating provider.

(3) If the health care plan's attempts to negotiate reimbursement for

health care services provided by a non-participating provider does not

result in a resolution of the payment dispute between the

non-participating provider and the health care plan, the health care

plan shall pay the non-participating provider an amount the health care

plan determines is reasonable for the health care services rendered,

except for the insured's copayment, coinsurance or deductible, in

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

insurance law, and shall ensure that the insured shall incur no greater

out-of-pocket costs for the surprise bill than the insured would have

incurred with a participating provider.

(4) Either the health care plan or the non-participating provider may

submit the dispute regarding the surprise bill for review to an

independent dispute resolution entity, provided however, the health care

plan may not submit the dispute unless it has complied with the

requirements of paragraphs one, two and three of this subsection.

* (5) 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

* (5) 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

(6) When determining a reasonable fee for the services rendered, the

independent dispute resolution entity shall select either the health

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

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) Surprise bill received by a patient who is not an insured.

(1) A patient who is not an insured and who receives a surprise bill

may submit a dispute regarding the surprise bill for review to an

independent dispute resolution entity.

(2) The independent dispute resolution entity shall determine a

reasonable fee for the services rendered based upon the conditions and

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

(3) A patient shall not be required to pay the physician's fee to be

eligible to submit the dispute for review to the independent dispute

resolution entity.

(c) The determination of an independent dispute resolution entity

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

shall be admissible in any court proceeding between the patient or

insured, provider or health care plan, or in any administrative

proceeding between this state and the provider.