607. Dispute resolution for surprise bills. (a) Surprise bill received by an insured who assigns benefits. (1) If an insured assigns benefits to a non-participating physician, the health care plan shall pay the non-participating physician in accordance with paragraphs two and three of this subsection.
(2) The non-participating physician may bill the health care plan for the health care services rendered, and the health care plan shall pay the non-participating physician the billed amount or attempt to negotiate reimbursement with the non-participating physician.
(3) If the health care plan's attempts to negotiate reimbursement for health care services provided by a non-participating physician does not result in a resolution of the payment dispute between the non-participating physician and the health care plan, the health care plan shall pay the non-participating physician an amount the health care plan determines is reasonable for the health care services rendered, except for the insured's copayment, coinsurance or deductible, in accordance with section three thousand two hundred twenty-four-a of the insurance law.
(4) Either the health care plan or the non-participating physician may submit the dispute regarding the surprise bill for review to an independent dispute resolution entity, provided however, the health care plan may not submit the dispute unless it has complied with the requirements of paragraphs one, two and three of this subsection.
(5) The independent dispute resolution entity shall make a determination within thirty days of receipt of the dispute for review.
(6) When determining a reasonable fee for the services rendered, the independent dispute resolution entity shall select either the health care plan's payment or the non-participating physician's fee. An independent dispute resolution entity shall determine which amount to select based upon the conditions and factors set forth in section six hundred four of this article. If an independent dispute resolution entity determines, based on the health care plan's payment and the non-participating physician's fee, that a settlement between the health care plan and non-participating physician is reasonably likely, or that both the health care plan's payment and the non-participating physician's fee represent unreasonable extremes, then the independent dispute resolution entity may direct both parties to attempt a good faith negotiation for settlement. The health care plan and non-participating physician may be granted up to ten business days for this negotiation, which shall run concurrently with the thirty day period for dispute resolution.
(b) Surprise bill received by an insured who does not assign benefits or by a patient who is not an insured. (1) An insured who does not assign benefits in accordance with subsection (a) of this section or a patient who is not an insured and who receives a surprise bill may submit a dispute regarding the surprise bill for review to an independent dispute resolution entity.
(2) The independent dispute resolution entity shall determine a reasonable fee for the services rendered based upon the conditions and factors set forth in section six hundred four of this article.
(3) A patient or insured who does not assign benefits in accordance with subsection (a) of this section shall not be required to pay the physician's fee to be eligible to submit the dispute for review to the independent dispute entity.
(c) The determination of an independent dispute resolution entity shall be binding on the patient, physician and health care plan, and shall be admissible in any court proceeding between the patient or insured, physician or health care plan, or in any administrative proceeding between this state and the physician.
Last modified: February 3, 2019