Current through Register Vol. 46, No. 39, September 25, 2024
(a) For purposes of this Subpart:
(1) Coordination of benefits or COB means a
procedure that is intended to avoid claims payment delays and duplication of
benefits when a person is covered by two or more health insurers providing
benefits or services for medical, dental or other care or treatment by:
establishing an order in which plans pay their claims, providing the authority
for the orderly transfer of information needed to pay claims properly and
permitting a reduction of the benefits of a health insurer when, by the rules
established by section
52.23 of this Title (Regulation
No. 62), it does not have to pay its benefits first.
(2) Health care claim means a request for
payment for services rendered to an insured pursuant to the benefits provided
in a health insurance policy.
(3)
Health care provider means an entity licensed or certified pursuant to article
28, 36 or 40 of the Public Health Law; a facility licensed pursuant to article
19, 23 or 31 of the Mental Hygiene Law; a health care professional licensed,
registered or certified pursuant to title 8 of the Education Law; or a health
care provider comparably licensed, registered or certified by another state; or
a dispenser or provider of pharmaceutical products, services or durable medical
equipment.
(4) Health insurance
policy means a contract that provides benefits or services for medical, dental
or other health care or treatment.
(5) Health insurer means an insurer that
issues a health insurance policy.
(6) Remittance advice means a form on which a
health insurer indicates to a health care provider the details of the health
insurer's processing of a particular claim.
(7) Primary health insurer means a health
insurer whose benefits for a person's health care coverage must be determined
without taking the existence of coverage issued by any other health insurer
into consideration, pursuant to the COB rules in section
52.23 of this Title and the
provisions of the health insurer's policy or contract.
(8) Secondary health insurer means a health
insurer that is not a primary health insurer that may take into consideration
the benefits of the primary health insurer or insurers and the benefits of any
other accident and health coverage.
(b) This Subpart shall apply to a health
insurer authorized to write accident and health insurance pursuant to article
42 of the New York Insurance Law, a corporation licensed pursuant to article 43
of the Insurance Law, or an entity certified pursuant to article 44 of the
Public Health Law, with respect to a health care claim submitted under a health
insurance policy. This Subpart shall not apply to coordination of benefits
involving no-fault auto insurance policies, workers compensation polices or the
Medicare program.
(c) The
requirements of this section shall apply when an individual is covered, or
where there is a reasonable basis supported by specific information to believe
that the individual is covered, under more than one health insurance policy
that provides benefits or services for medical, dental or other care or
treatment.
