Current through Register Vol. 46, No. 39, September 25, 2024
(a) When a health care provider submits a
claim to a health insurer, that submission shall suspend the time period for
submission of the claim to a second health insurer until such time as the
provider has received a remittance advice or other evidence of a benefit
determination, including an appeal determination, from the first health
insurer. After the health care provider receives a remittance advice, appeal
determination, or other evidence of a benefit determination from the first
health insurer, the health care provider shall have at least 60 days from
receipt of the remittance, appeal determination or other evidence of a benefit
determination to bill any other health insurer that has a potential payment
obligation. A claim submitted to the second health insurer after the 60-day
period shall be subject to the claims submission rules of the second health
insurer. Unless the health care provider is otherwise able to demonstrate, it
shall be presumed that the remittance advice, appeal determination, or other
evidence of a benefit determination was received within eight calendar days of
the date on the document.
(b)
(1) If a health care provider submits a claim
to a secondary health insurer prior to submitting the claim to the primary
health insurer, the secondary health insurer shall deny the claim, notify the
health care provider that it is secondary and notify the health care provider
of the identity of the primary health insurer, or, if the identity of the
primary health insurer is not known, provide whatever information was used to
make the determination that it is a secondary health insurer. The secondary
health insurer may provide the information by referring the health care
provider to the specific page of the secondary health insurer's website and
shall include a toll free telephone number through which the information will
be provided. The health care provider's submission of the claim to the primary
health insurer shall suspend the time period for resubmission of such claim to
the secondary health insurer as set forth above in subdivision (a) of this
section.
(2) If the information
provided by the secondary health insurer is not sufficient to determine the
identity of the primary health insurer, the health care provider shall have 60
days from the notice that other coverage may exist to make a reasonable effort
to confirm if other coverage does exist. A "reasonable effort" shall include at
least an attempt by the health care provider to contact the patient.
(3) If the health care provider is unable to
confirm other coverage within 60 days as provided in paragraph (2) of this
subdivision, the secondary health insurer shall process the claim in accordance
with the provisions in the health insurance policy, provided that the health
care provider resubmits the claim to the secondary health insurer, with copies
of the documents to support the health care provider's efforts to confirm other
coverage, within 30 days of the determination that other coverage could not be
confirmed despite reasonable efforts.
(c)
(1) If
a secondary health insurer makes a payment to a health care provider prior to
determining the secondary health insurer's actual obligation to pay the claim,
the secondary health insurer shall delay any action to recover the payment,
pending a determination by the primary health insurer as to the primary health
insurer's obligation and a determination by the secondary health insurer of its
actual obligation to pay the claim. Subject to all provisions of this
subdivision, the secondary health insurer may recover the payment if the health
care provider does not submit a remittance advice, appeal determination, or
other evidence of a benefit determination from the primary health insurer to
the secondary health insurer within 120 days of the secondary health insurer's
notification that other coverage exists. Nothing herein shall prevent the
secondary health insurer from allowing more than 120 days to submit the
documents
(2) If the information
provided by the secondary health insurer is not sufficient to determine the
identity of the primary health insurer, the health care provider shall have 60
days from the notice that other coverage may exist to make a reasonable effort
to confirm if other coverage does exist. A "reasonable effort " shall include
at least an attempt by the health care provider to contact the
patient.
(3) If the health care
provider is unable to confirm other coverage within 60 days as provided in
paragraph (2) of this subdivision, the secondary health insurer shall process
the claim in accordance with the provisions in the member's health insurance
policy, provided that the health care provider notifies the secondary health
insurer and forwards copies of the documents to support the health care
provider's efforts to confirm other coverage, within 30 days of the
determination that other coverage could not be confirmed despite reasonable
efforts.
(d) If a health
care provider receives approval from a health insurer to provide services to
the health insurer's insured, prior to the rendering of those services to the
insured, a second health insurer shall not subsequently deny a claim for the
services on the basis that no prior approval from that health insurer was
received. The fact that one health insurer has given a health care provider
prior approval does not, however, preclude another health insurer from
determining that the services that were provided were not medically necessary
or otherwise not covered under the policy.
(e) Every determination of the primary health
insurer and secondary health insurer shall comply with section
3224-a of the
Insurance Law.
