Current through Register Vol. 46, No. 39, September 25, 2024
(a)
(1) If
a professional health service reimbursable under Insurance Law section
5102(a)(1) is performed outside this State, the amount that the insurer shall
reimburse for [such] the service shall be the lower of the amount charged by
the provider and the prevailing fee in the geographic location of the provider
with respect to services:
(i) that constitute
emergency care;
(ii) provided to an
eligible injured person that is not a resident of this State; or
(iii) provided to an eligible injured person
that is a resident of this State who, at the time of treatment, is residing in
the jurisdiction where the treatment is being rendered for reasons unrelated to
the treatment.
(2) For
purposes of this subdivision, emergency care means all medically necessary
treatment initiated within 48 hours of a motor vehicle accident for a traumatic
injury or a medical condition resulting from the accident, which injury or
condition manifests itself by acute symptoms of sufficient severity such that
absence of immediate attention could reasonably be expected to result in:
death; serious impairment to bodily functions; or serious dysfunction of a
bodily organ or part. Medically necessary treatment shall include immediate
pre-hospitalization care, transportation to a hospital or trauma center,
emergency room care, surgery, critical and acute care. Emergency care extends
during the period of initial hospitalization until the patient is discharged
from the hospital.
(b)
Except as provided in subdivision (a) of this section, if a professional health
service reimbursable under Insurance Law section 5102(a)(1) is performed
outside this State with respect to a n eligible injured person that is a
resident of this State, the amount that the insurer shall reimburse for the
service shall be the lowest of:
(1) the
amount of the fee set forth in the region of this State that has the highest
applicable amount in the fee schedule for that service;
(2) the amount charged by the provider;
and
(3) the prevailing fee in the
geographic location of the provider.
(c) If the jurisdiction in which the
treatment is being rendered has established a fee schedule for reimbursing
health services rendered in connection with claims for motor vehicle-related
injuries and the fee schedule applies to the service being provided, the
prevailing fee amount specified in subdivisions (a) and (b) of this section
shall be the amount prescribed in that jurisdiction's fee schedule for the
respective service.
