Uniform Notice OON Bill

Emergency Services:
If your claim is for emergency services you received in a hospital from a non-participating doctor, you should not pay more in out-of-pocket costs for the services than you would have paid if the doctor was in our network. If the non-participating doctor bills you for more than your in-network cost-sharing for the out-of-network emergency service, please contact us at the number on the back of your member ID card. You may also visit our website at emblemhealth.com/outofnetwork for more information about protections that apply to emergency services and “surprise bills.” Note that your cost-sharing may increase if an independent dispute resolution entity (IDRE) later decides that we must pay more for the services of the non-participating doctor.

Out-of-Network Services & “Surprise Bills”:
If your claim was for services from a non-participating provider, the claim may be for a “surprise bill,” giving you protection from out-of-pocket costs in excess of what you would have paid in-network for the services. Please contact us at the number on the back of your member ID card or visit our website at emblemhealth.com/outofnetwork for more information about what constitutes a “surprise bill” and what you should do if you think your claim was for a “surprise bill.”

If your claim was for a “surprise bill,” you should not pay more in out-of-pocket costs for the services than you would have paid if the provider had been in our network. If the
non-participating provider bills you for any amounts above your in-network cost-sharing (copay, deductible and/or coinsurance) for the surprise bill or if we did not recognize your claim as a “surprise bill,” please contact us at the number on the back of your member ID card and/or visit our website at emblemhealth.com/outofnetwork for more information about “surprise bills” and further instructions. Note that your cost-sharing for the services may increase if an independent dispute resolution entity (IDRE) later decides that we must pay more for the services of the non-participating provider.

If we paid you directly for a claim for out-of network services and you later submit to us a completed assignment of benefits form for surprise bills in connection with those services, you must send our payment to the non-participating provider that rendered the service.

NOTE: If your 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 you are covered by Medicare, or if your plan does not have a provider network, or if you received services outside of New York State, some or all of the rights and protections described above for Emergency Services and Out-of-Network Services & Surprise Bills may not apply to your claim or may differ.