You will not be responsible for the costs of "surprise bills" for out-of-network services, other than any in-network cost-sharing (in-network copay, coinsurance and/or deductible) that applies under your plan.
What's a "surprise bill"? What are some examples?
Not all out-of-network services are surprise bills. A surprise bill is a bill for covered non-emergency health care services rendered on or after March 31, 2015, where one of the following situations applies:
1) You receive covered health services from an out-of-network doctor at an in-network hospital or ambulatory surgical center, in any one of the following circumstances:
- An in-network doctor is unavailable
Example 1: You are not told that the scheduled in-network surgeon stepped out of the procedure and an out-of-network surgeon stepped in.
Example 2: An out-of-network anesthesiologist performs services during your surgical procedure without your knowing of the anesthesiologist's out-of-network status.
- An out-of-network doctor delivers services and you didn't know that doctor was out of network
Example 1: You receive covered health services at an in-network ambulatory surgical center, and during that visit an out-of-network anesthesiologist provides services to you, without your knowing of that doctor's out-of-network status.
Example 2: An in-network ambulatory surgical center sends your lab specimen to an out-of-network lab or pathologist.
- You need unexpected medical services while receiving other services
Example: Unexpected medical needs arise and an out-of-network surgeon is brought in to perform the unexpected services.
If a network provider was available and you elected to receive services from a non-participating doctor anyway, then it is not a surprise bill.
3) An uninsured individual receives health services from a doctor at a hospital or ambulatory surgical center, where the health care provider did not give the individual certain required information.
How does EmblemHealth process claims for non-emergency surprise bills?
If EmblemHealth gets a claim for out-of-network services that seem to be related to a surprise bill, but that isn't submitted with a completed surprise bill Assignment of Benefits Form, EmblemHealth will send you a notice —either within, or together with, your Explanation of Benefits —explaining that the claim could be a surprise bill, and that you should contact EmblemHealth or refer to this web page for instructions on what to do next.
If EmblemHealth gets a claim for out-of-network services along with a completed surprise bill Assignment of Benefits Form, or a claim that we determine is a surprise bill without also receiving a surprise bill Assignment of Benefits Form, we will send you a notice explaining that:
- Your out-of-pocket costs for the services related to the surprise bill won't be any higher than if you'd received them from an in-network doctor,
- Your cost-sharing for the services may increase if an IDRE (independent dispute resolution entity) decides that EmblemHealth must pay an additional amount(s) to the provider for the services, and
- You should contact EmblemHealth if the out-of-network doctor bills you for the out-of-network service.
What if EmblemHealth doesn't know a claim should be handled as a surprise bill?
In some cases, it may not be clear to EmblemHealth that a claim relates to a surprise bill. In such cases, we may deny the claim if you have only in-network coverage, such as HMO or EPO coverage.
If your plan includes out-of-network benefits (usually called a PPO or POS plan), we will process the claim according to the terms and conditions that normally apply to out-of-network services —which usually involve higher cost-sharing and higher out-of-pocket costs than for covered in-network services.
If you feel EmblemHealth should have processed a claim as a surprise bill, you should complete a surprise bill Assignment of Benefits Form and submit it to EmblemHealth. You also have the option to dispute our decision on the claim by filing a grievance.
For the address and other contact options for submitting forms, and for instructions on filing a grievance, see the section on this page "Disputing Claims for Out-of-Network Emergency Services or Surprise Bills."