Surprise Billing Information

What you need to know to protect yourself from surprise bills if you have coverage with an HMO or insurer subject to New York law (coverage that is not self-insured; CareConnect is an insurer subject to New York law)

• What is a surprise bill?

  When you receive services from an out-of-network doctor at an in-network hospital or ambulatory surgical center, the bill you receive for those services is a surprise bill if one of the following applies:

  • An in-network doctor was not available.
  • An out-of-network doctor provided services without your knowledge.
  • Unforeseen medical circumstances arose at the time the services were provided.

  It is not a surprise bill if you chose to receive services from an out-of-network doctor instead of from an available in-network doctor.

  When you are referred by your in-network doctor to an out-of-network provider, the bill you receive for those services is a surprise bill if you did not sign a written consent that you knew the services would be out-of-network and would result in costs not covered by your health plan. A referral to an out-of-network provider occurs in any of the following circumstances:

  • During a visit with your in-network doctor, an out-of-network provider treats you.
  • Your in-network doctor takes a specimen (such as a blood specimen) from you in the office and sends it to an out-of-network laboratory or pathologist.
  • You receive any other health care services when referrals are required under your plan.
• How can I protect myself from a surprise bill?

  You will be protected from a surprise bill and will be responsible only for your in-network copayment, coinsurance or deductible if you do both of the following:

  • Sign an assignment of benefits form to permit your provider to seek payment for the bill from your health plan.
  • Send the form to your health plan and to your provider, and include a copy of the bill or bills you do not think you should pay. CareConnect members should send the form and bill (or bills) to the attention of the Appeals and Grievances Department in one of two ways:
    • Scan and send them in an email to questions@careconnect.com 
    • Mail them to:
      CareConnect
      Attn: Appeals and Grievances Department
      2200 Northern Blvd., Suite 104
      East Hills, NY 11548.

What you need to know about surprise bills if you are a health care provider

• What are my obligations if my patient has coverage through an HMO or insurer subject to New York law (coverage that is not self-insured)?

  Hospital and ambulatory surgical center. A bill is a surprise bill if your patient receives services from an out-of-network doctor at an in-network hospital or ambulatory surgical center and: 

  • An in-network doctor was not available; or 
  • An out-of-network doctor provided services without your patient’s knowledge; or 
  • Unforeseen medical circumstances arose at the time the health care services were provided.

  Referral. A bill is a surprise bill if your patient is referred by an in-network doctor to an out-of-network provider, and your patient did not sign written consent acknowledging that the services would be out-of-network and would result in costs not covered by the patient’s health plan. A referral occurs if:

  • During the course of a visit with an in-network doctor, an out-of-network provider treats the patient; or 
  • The patient’s in-network doctor takes a specimen from the patient in the office (for example, blood) and sends it to an out-of-network laboratory or pathologist; or 
  • The patient receives any other health care services when referrals are required under the patient’s plan.

  Assignment of benefits form. When your patient signs an assignment of benefits form for a surprise bill, your patient will be responsible for paying you only the in-network cost-sharing. You are required to hold your patient harmless for any amounts in excess of your patient’s in-network cost-sharing, and your patient’s health plan will pay you directly for the services. The health plan is required to pay you the billed amount or attempt to negotiate reimbursement with you. If attempts to negotiate do not result in a resolution of the payment dispute, the health plan will pay you an amount that it determines is reasonable. You may dispute the amount that the health plan pays you through the independent dispute resolution process.

  When you bill a patient. If you are a doctor and are billing a patient for what could be a surprise bill, you are required to include an assignment of benefits form and a claim form for a third-party payer when you send the bill to the patient.

Emergency services (Insurance Law Section 3241(c) and Financial Services Law Article 6)

• What are “hold harmless protections” for insured patients?

  Your health plan must protect you from bills for out-of-network emergency services in a hospital if you have coverage through an HMO or an insurer subject to New York law (coverage that is not self-insured). You do not have to pay out-of-network provider charges for emergency services (typically for services in a hospital emergency room) that are more than your in-network copayment, coinsurance or deductible (this protection may apply only if your health insurance coverage was renewed after March 31, 2015). Let CareConnect know if you receive a bill from an out-of-network provider for emergency services.

• What are my options as a doctor?

  You may dispute the amount that the health plan pays you for emergency services through the independent dispute resolution process if you do not participate with a patient’s health plan. However, the following emergency services are exempt from the that process: CPT codes 99281–99285, 99288, 99291–99292, 99217–99220, 99224–99226 and 99234–99236, if the bill does not exceed 120% of the usual and customary cost and the fee disputed is $613.50 (adjusted annually for inflation rates) or less after any applicable coinsurance, copayment and deductible.

The independent dispute resolution (IDR) process (Financial Services Law Article 6)

• As a health care provider, how do I submit a dispute with a health plan involving an insured patient?

  You should submit your dispute through the independent dispute resolution (IDR) process for surprise bills or emergency services. As a provider, you must:

  • Visit the Department of Financial Services website to receive a file number.
  • Complete this application.
  • Send the application to the assigned independent dispute resolution entity.
• How do I submit a dispute if I’m an uninsured patient, a patient with employer or union self-insured coverage, or an insured person who did not sign an assignment of benefits form for surprise bills?

  To submit a dispute, you must complete this application and send it to the New York State Department of Financial Services, Consumer Assistance Unit/IDR Process, One Commerce Plaza, Albany, NY 12257.

• Who do I contact if I have questions about submitting a dispute?

  For help, call the New York State Department of Financial Services at 800-342-3736 or email IDRquestions@dfs.ny.gov.

• What is the IDR process for the review of surprise bills and bills for emergency services?

  This process includes several components:

  1. An independent dispute resolution entity (IDRE) reviews the dispute. Decisions will be made by a reviewer with training and experience in health care billing, reimbursement, and usual and customary charges, in consultation with a licensed doctor in active practice in the same or a similar specialty as the doctor providing the service that is the subject of the dispute. The IDRE will make a determination within 30 days of receipt of the dispute.
  2. The IDRE determines the fee. For disputes involving HMO or insurance coverage, the IDRE chooses either the out-of-network provider bill or the health plan payment. For disputes submitted by uninsured patients, or by patients with employer or union self-insured coverage, the IDRE determines the fee.
  3. The IDRE considers these factors when making a determination:

  • Whether there is a gross disparity between the fee charged by the provider and (1) fees paid to the provider for the same services provided to other patients in health care plans in which the provider is out-of-network, and (2) the fees paid by the health plan to reimburse similarly qualified out-of-network providers for the same services in the same region
  • The provider’s training, education, experience and usual charge for comparable services when the provider does not participate with the patient’s health plan
  • The circumstances and complexity of the case
  • Patient characteristics
  • The usual and customary cost of the service

  1. The IDRE may direct a good-faith negotiation for settlement if settlement is likely or if the health plan’s payment and the provider’s fee are unreasonably far apart.
  2. The review is binding and admissible in court.
• Who pays for the IDR?

  For disputes between a provider and a health plan involving an insured patient, these are the possible outcomes:

  • The provider pays the cost of the dispute resolution when the IDRE determines that the health plan’s payment is reasonable.
  • The health plan pays the cost of the dispute resolution when the IDRE determines that the provider’s fee is reasonable.
  • The provider and the health plan share the pro-rated cost when there is a settlement.
  • The provider or health plan submitting the dispute may be charged a minimal fee if the dispute is found ineligible or incomplete.

  For disputes involving a patient who is not an insured, these are the possible outcomes:

  • The doctor pays the cost of the dispute resolution when the IDRE determines that the doctor’s fee is not reasonable.
  • The patient pays the cost of the dispute resolution when the IDRE determines that the doctor’s fee is reasonable, unless it would pose a hardship to the patient. (“Hardship” means a household income below 250% of the federal poverty level.)
• Who should I contact if I have questions about independent dispute resolution?

  If you have questions or need help completing an application, call the New York State Department of Financial Services at 800-342-3736 or email IDRquestions@dfs.ny.gov.