(Insurance Law Sections 3217-a, 3217-b, 3217-d, 3241, 4306-c, 4324, 4325 & 4804 and Public Health Law Sections 4403 & 4408)
This New York state law will help you avoid surprise bills and unexpected expenses when receiving out-of-network care. Plus, it protects you in the case that you must go out of network for a specialist or procedure when they are not available within your plan’s provider network.
Understanding Your Rights to Access Out-of-Network Care
Right to Go Out-of-Network When Independent Health Does Not Have An In-Network Provider:
- When Independent Health does not have an in-network provider with the appropriate training and experience to meet your particular health care needs, you may get approval to receive care from an out-of-network provider for no additional cost beyond what you would pay to see an in-network provider.
- Contact Independent Health to receive information on how to obtain approval to an out-of-network provider.
Right to Go Out-of-Network When Independent Health Does Have An In-Network Provider:
- Even when Independent Health does have an in-network provider with the appropriate training and experience to meet your particular health care needs, you may choose to seek medically necessary services from an out-of-network provider. However, when doing so, you will need to pay any applicable out-of-network cost according to your General Health Contract or GHC (GHC). To estimate what these out-of-network costs may be, visit http://www.fairhealthconsumer.org
- If your GHC does not provide out-of-network coverage, then services will not be covered.
See examples of what it may cost for you to go out of network.
Protection from Surprise Bills for Health Care Services
(Financial Services Law Article 6)
A Surprise Bill is when you receive services in a hospital or surgical center and the following occurs:
- A participating doctor was not available, so you received care from a non-participating doctor;
- A non-participating doctor provided services without your knowledge; or
- Unforeseen medical circumstances arose at the time the health care services were provided. Please note: It will NOT be a surprise bill if you chose to receive services from a non-participating doctor instead of from an available participating doctor.
Protect Yourself From a Surprise Bill
You will be protected from a surprise bill and you will only be responsible for your in-network copayment, coinsurance or deductible if you:
- Complete an Assignment of Benefits Form – Signing this form permits your provider to seek payment for the bill from your health plan.
- Send the Signed Form and Bill(s) to Independent Health and Your Provider – Include a copy of the bill or bills you do not think you should pay.
How to Submit a Dispute for Independent Dispute Resolution
A non-participating physician, the health plan, or a member who does not submit the Assignment of Benefits Form can submit a dispute to an independent dispute resolution entity for review of payment of a surprise bill.
- When a member assigns benefits, the health plan is required to pay the billed charges or negotiate reimbursement with the non-participating physician. The member is responsible for the applicable copayment, coinsurance, or deductible that would be owed if a participating physician was used.
- When a member seeks care from a non-participating physician, negotiations between the health plan and the non-participating physician will take place. If these negotiations are unsuccessful, the plan will be allowed to pay an amount it determines as reasonable.
- The non-participating physician can submit the dispute in payment to the entity for review. The plan cannot submit to the entity to dispute unless it has complied with the payment and negotiation requirements.
- In order to file an independent dispute resolution, you, the physician, or the health plan may contact the Customer Assistance Bureau.
- If a health provider does not believe that a bill meets the definition of a surprise bill, they may contact the Consumer Assistance Bureau of the Department of Financial Services and may submit any relevant information and begin the independent dispute resolution process.
You may submit a claim or Assignment of Benefits Form to us by mail or email by sending it to the following:
P.O. Box 9066
Buffalo, NY 14231
Attn: Claims Department