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 400.3 - Independent dispute resolution entity (IDRE) certification requirements
Universal Citation: 23 NY Comp Codes Rules and Regs ยง 400.3
Current through Register Vol. 46, No. 12, March 20, 2024
(a) An entity applying to be an IDRE certified to perform reviews regarding bills for emergency services , including inpatient services that follow an emergency room visit, and surprise bills pursuant to Financial Services Law Article 6 shall submit to the superintendent:
(1) a
description of the proposed IDRE's organizational structure and capability to
operate a statewide IDRE, including:
(i) a
certificate of incorporation, articles of organization and bylaws or operating
agreement of the proposed IDRE and, as applicable, those of the proposed IDRE's
holding company or parent company;
(ii) the proposed IDRE's organizational
chart;
(iii) identification of
management staff and a description of such management staff's
responsibilities;
(iv) the name and
credentials of a medical director appointed by the proposed IDRE, who is a
physician in possession of a current and valid non-restricted license to
practice medicine in New York;
(v)
the names and biographies of all controlling employees, officers, and
executives of the proposed IDRE; and information concerning the governing board
of the proposed IDRE, including roles and responsibilities, identification of
the board members and a description of their qualifications;
(2) a sworn statement, as
described in section
400.4(b)
of this Part, signed by the chief executive officer of the proposed IDRE
regarding conflicts of interest;
(3) the names of all corporations and
organizations that control, are controlled by, or under common control with the
proposed IDRE, and the nature and extent of any such control;
(4) the proposed IDRE's policies and
procedures governing all aspects of the dispute resolution process, including
at a minimum:
(i) a description and a chart or
diagram of the sequence of steps through which a dispute will move from receipt
through notification to the health care plan, physician, superintendent, and
provider, insured, or patient, if applicable, regarding the dispute
determination;
(ii) procedures for
ensuring that no prohibited material familial, financial or professional
affiliation exists with respect to the reviewer and reviewing physician
assigned to the dispute. The procedures shall include, for each reviewer and
reviewing physician assigned to review a dispute, a requirement for a signed
attestation affirming, under penalty of perjury, that no prohibited material
familial, financial or professional affiliation exists with respect to the
reviewer's or reviewing physician's participation in the review of the
dispute;
(iii) procedures to ensure
that the dispute is reviewed by a neutral and impartial reviewer with training
and experience in healthcare billing, reimbursement, and usual and customary
charges and determinations are made in consultation with a neutral and
impartial licensed reviewing physician in active practice in the same or
similar specialty as the physician providing the service that is subject to the
dispute, who is also, to the extent practicable, licensed in New
York;
(iv) procedures for the
reporting and review of reviewer's and reviewing physician's conflicts of
interest and for assigning or reassigning a dispute resolution where a conflict
or potential conflict is identified;
(v) procedures to ensure that reviews are
conducted within the time frames specified in section
400.8
of this Part and any required notices are provided in a timely
manner;
(vi) procedures to ensure
the confidentiality of medical and treatment records and review materials;
and
(vii) procedures to ensure
adherence to the requirements of this Part by any contractor, subcontractor,
agent or employee affiliated by contract or otherwise with the proposed
IDRE;
(5) a description
of the reviewer and reviewing physician network, including:
(i) an assessment of the proposed IDRE's
ability to provide review services statewide;
(ii) a description of the qualifications of
the reviewers and reviewing physicians retained to review payment disputes,
including current and past employment history and practice affiliations, as
applicable;
(iii) a description of
the procedures employed to ensure that reviewers and reviewing physicians
reviewing payment disputes are:
(a)
appropriately licensed, registered or certified, if applicable;
(b) trained in the principles, procedures and
standards of the proposed IDRE;
(c)
knowledgeable about the health care service which is the subject of the payment
dispute under review; and
(d) with
respect to reviewers, trained and experienced in health care billing,
reimbursement and usual and customary charges;
(iv) a description of the methods of
recruiting and selecting neutral and impartial reviewers and reviewing
physicians and matching such reviewers and reviewing physicians to specific
cases;
(v) the number of reviewers
and reviewing physicians retained by the proposed IDRE, and a description of
the areas of expertise available from reviewing physicians and the types of
cases reviewing physicians are qualified to review;
(vi) the proposed IDRE's quality assurance
program, which shall include written descriptions, to be provided to all
individuals involved in such program; the organizational arrangements and
ongoing procedures for the identification, evaluation, resolution and follow-up
of potential and actual problems in payment dispute reviews performed by the
reviewer and reviewing physician; and the maintenance of program standards
pursuant to this subdivision; and
(vii) written procedures documenting that:
(a) appropriate personnel are reasonably
accessible not less than 40 hours per week during normal business hours to
discuss the dispute resolution process and to allow response to telephone
requests;
(b) a response to an
accepted or recorded message shall be made not less than one business day after
the date on which the call was received; and
(viii) documentation of accreditation by a
nationally recognized private accrediting organization, if accreditation is
available;
(6) a list of
its fees, which shall reflect the total amount that will be charged by the
proposed IDRE for reviews, inclusive of indirect costs, administrative fees and
incidental expenses, and a description of the methodology used to calculate the
fees. The description shall include the pro-rated fee that will be charged when
a good faith negotiation directed by the proposed 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 description also shall include an application processing fee when the
dispute is determined by the proposed IDRE to be ineligible for review. The
description shall provide a waiver of the fee for disputes submitted by
patients when the fee would pose a financial hardship to the patient;
(7) a description of the proposed IDRE's
ability to accept requests for reviews, provide requisite notifications, screen
for material affiliations, respond to calls from the State and meet other
requirements during normal business hours; and
(8) such other information as the
superintendent may require.
(b) An IDRE may not charge any fee unless it has been filed with the superintendent and the superintendent has determined that the fee is reasonable.
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