New York Codes, Rules and Regulations
Title 23 - FINANCIAL SERVICES
Chapter I - Regulations of the Superintendent of Financial Services
Part 400 - Independent Dispute Resolution for Emergency Services and Surprise Bills
Section 400.10 - Payment for the independent dispute resolution
Universal Citation: 23 NY Comp Codes Rules and Regs ยง 400.10
Current through Register Vol. 46, No. 39, September 25, 2024
(a) Disputes involving an insured.
(1) If an IDRE determines the
health care plan's payment, or best and final offer, as applicable, is
reasonable, payment for the dispute resolution process shall be the
responsibility of the non-participating physician, non-participating hospital,
or as applicable, nonparticipating referred health care provider.
(2) If an IDRE determines the
non-participating physician's or non-participating referred health care
provider's fee or the non-participating hospital's fee or best and final offer,
as applicable, is reasonable, payment for the dispute resolution process shall
be the responsibility of the health care plan.
(3) If good faith negotiations directed by
the IDRE results in a settlement between the health care plan and the
non-participating physician, non-participating hospital or non-participating
referred health care provider, the health care plan and the non-participating
physician, non-participating hospital or non-participating referred health care
provider shall evenly divide and share the prorated cost for dispute
resolution.
(4) For disputes that
are rejected as ineligible or due to the requesting non-participating
physician, nonparticipating hospital, nonparticipating referred health care
provider or health care plan's failure to submit information, an IDRE may
charge an application processing fee, which shall be the responsibility of the
requesting physician, hospital, health care provider or health care
plan.
(b) Disputes involving a patient who is not an insured.
(1) If an IDRE determines the physician's or
hospital's fee is reasonable, payment for the independent dispute resolution
process shall be the responsibility of the patient. If the superintendent
determines that payment would pose a hardship to the patient pursuant to
subdivision (c) of this section, the IDRE shall waive payment for the dispute
resolution process.
(2) If an IDRE
determines the physician's or hospital's fee is not reasonable, payment for the
independent dispute resolution process shall be the responsibility of the
physician or hospital.
(c) A hardship shall exist if the household income of the patient who is not an insured is below 250 percent of the Federal poverty level, as determined annually by the Secretary of Health and Human Services.
(d) Any payments due to an IDRE under this section shall be made to the IDRE within 30 calendar days from receipt of the IDRE's written determination and invoice.
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