Surprise Bills and Emergency Services Uniform Notice for Out of Network Providers

Date Issued: 2/2/2016

Emergency Services
If you are a physician and we are paying you directly for emergency services and you disagree with our payment, you may initiate the dispute resolution process by completing the IDRE application form, which can be found at dfs.ny.gov. We will pay the amount, if any, determined by the IDRE for the services. Do not bill our member for amounts in excess of the in-network cost-sharing shown on the explanation of payment for the services.

Surprise Bills
If we have paid you for a “surprise bill” as defined by New York State law, that payment is in reasonable settlement of the surprise bill. If you disagree with any payment made, please call the customer service phone number on the back of the member’s ID card to discuss additional payment. You may also initiate the independent dispute resolution process by completing the IDRE application form, which can be found at dfs.ny.gov. The IDRE will determine whether our payment or your charge is reasonable within 30 days of receiving the dispute. Do not bill our member for amounts in excess of the in-network cost-sharing shown on the explanation of payment for the services for a surprise bill.

NOTE: If your patient’s health plan is self-insured, non-comprehensive (e.g. a medical only, hospital only or limited benefits plan) or exempt from New York State insurance law, or if your patient is covered by Medicare, or if your patient’s plan does not have a provider network, or if the services were rendered outside of New York State, some or all of the information above about Emergency Services and Out-of-Network Services & Surprise Bills may not apply or may differ.