N.Y. Insurance Law § 3235: Explanation of benefits forms relating to claims under medicare supplemental insurance policies and limited benefits health insurance pol...

§ 3235. Explanation of benefits forms relating to claims under

medicare supplemental insurance policies and limited benefits health

insurance policies or certificates designed primarily to supplement

medicare benefits. (a) Every insurer issuing medicare supplement

insurance policies or certificates and limited benefits health insurance

policies or certificates designed primarily to supplement medicare

benefits, including health maintenance organizations operating under

article forty-four of the public health law or article forty-three of

this chapter and any other corporation operating under article

forty-three of this chapter, is required to provide the insured or

subscriber with an explanation of benefits form in response to the

filing of any claim under such policy or certificate.

(b) The explanation of benefits form must include at least the

following:

(1) the name of the provider of service and the admission or financial

control number, to the extent that they are included in the information

received on the medicare claim from the medicare carrier or intermediary

or from the beneficiary;

(2) a statement that the name and address of the provider of service,

an identification of the service, the amount charged for the service,

and the medicare approved amount are specified on the medicare

explanation of benefits form to which the claim corresponds;

(3) the date of service;

(4) the amount of the benefit payable under the policy or certificate,

including, if applicable, any amount exceeding medicare's approved

charge;

(5) when payment under the policy or certificate is based upon the

medicare approved charge and does not include any part of a charge which

exceeds the medicare approved charge, a statement that the policy or

certificate only provides reimbursement for the difference between the

medicare approved charge and the medicare payment, that charges in

excess of the medicare approved charge may be subject to limitations

pursuant to section nineteen of the public health law, that the insured

or subscriber has a right to appeal the medicare approved charge by

writing to medicare's carrier or fiscal intermediary, and that the

insured or subscriber may be responsible for the amount by which the

charge exceeds the medicare approved charge; and

(6) a telephone number or address where an insured or subscriber may

obtain clarification of the explanation of benefits, as well as a

description of the time limit, place and manner in which an appeal of a

denial of benefits must be brought under the policy or certificate and a

notification that failure to comply with such requirements may lead to

forfeiture of a consumer's right to challenge a denial or rejection,

even when a request for clarification has been made.

(c) Except on demand by the insured or subscriber, insurers, including

health maintenance organizations operating under article forty-four of

the public health law or article forty-three of this chapter and any

other corporation operating under article forty-three of this chapter,

issuing medicare supplement insurance policies or limited benefits

health insurance policies or certificates designed primarily to

supplement medicare benefits shall not be required to provide the

insured or subscriber with an explanation of benefits form in any case

where the service is provided by a facility or provider on an assignment

basis and the insurer's reimbursement is paid directly to the facility

or provider.