New York Laws
Article 6 - Emergency Medical Services and Surprise Bills
607 - Dispute Resolution for Surprise Bills.

(2) The non-participating provider may bill the health care plan for
the health care services rendered, and the health care plan shall pay
the non-participating provider the billed amount or attempt to negotiate
reimbursement with the non-participating provider.
(3) If the health care plan's attempts to negotiate reimbursement for
health care services provided by a non-participating provider does not
result in a resolution of the payment dispute between the
non-participating provider and the health care plan, the health care
plan shall pay the non-participating provider 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, and shall ensure that the insured shall incur no greater
out-of-pocket costs for the surprise bill than the insured would have
incurred with a participating provider.
(4) Either the health care plan or the non-participating provider 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 business 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 provider'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 provider's fee, that a settlement between the health
care plan and non-participating provider is reasonably likely, or that
both the health care plan's payment and the non-participating provider'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
provider may be granted up to ten business days for this negotiation,
which shall run concurrently with the thirty business day period for
dispute resolution.
(b) Surprise bill received by a patient who is not an insured.
(1) 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 shall not be required to pay the physician's fee to be
eligible to submit the dispute for review to the independent dispute
resolution entity.
(c) The determination of an independent dispute resolution entity
shall be binding on the patient, provider and health care plan, and
shall be admissible in any court proceeding between the patient or
insured, provider or health care plan, or in any administrative
proceeding between this state and the provider.

Structure New York Laws