- You’re only responsible for paying your share of the cost (like the copayment, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
- Generally, your health plan must:
- Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your Explanation of Benefits.
- Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.
If you are a member enrolled in a New York insured plan and think you’ve been wrongly billed, you can also contact the New York State Department of Financial Services at (800) 342-3736 or visit https://www.dfs.ny.gov/consumers/health_insurance/surprise_medical_bills.
If you are a member enrolled in a self-funded plan, and you think you’ve been wrongly billed, state law protections may not apply, but you may have protections under federal law. Visit https://www.cms.gov/nosurprises for information about your rights under federal law.
Your rights may differ from those described above if you are covered by Medicare or other government programs, or if your plan:
- is non-comprehensive (e.g. dental only, vision only, etc.); or
- does not have a provider network.
What To Do If You Receive a Surprise Bill Or A Bill For Emergency Services
If You Are a Member Enrolled in a Fully-Insured EmblemHealth Plan:
A surprise bill is when an out-of-network provider treats you at an in-network hospital or ambulatory surgical center OR you are referred by an in-network doctor to an out-of-network provider. It is NOT a surprise bill if you chose to receive services from an out-of-network provider instead of from an available in-network provider before you got to the hospital or ambulatory surgical center. For a surprise bill, you are only responsible for your in-network copayment, coinsurance or deductible.
What to Do if You Get a Bill for Emergency Services.
If you get a bill for emergency services, contact EmblemHealth at the telephone number on the back of your ID card. You are only responsible for your in-network copayment, coinsurance or deductible.
What to Do if You Get a Surprise Bill.
1. Complete and sign the Surprise Bill Certification Form. You must sign a Surprise Bill Certification Form if:
Your in-network doctor referred you to an out-of-network provider; or
An out-of-network provider treated you at an in-network hospital or ambulatory surgical facility before January 1, 2022. The form is not required for services provided on or after January 1, 2022, but it is recommended.
Surprise Bill Certification Form
2. Send Form and Bill. Send the completed form to EmblemHealth and to the out of network provider and include a copy of the bill(s) you do not think you should pay.
Send the form and bill to EmblemHealth at the address(es) below, and also include a completed claim form or the Explanation of Benefits related to the service(s).
If You Are a Member Enrolled in Self-Funded Coverage or FEHBP:
The Federal No Surprises Act protects you from surprise medical bills from an out-of-network provider in an in-network hospital or ambulatory surgical center for plans issued or renewed on and after January 1, 2022. You are only responsible for your in-network cost-sharing (copayment, coinsurance, or deductible) for a surprise bill. If you receive a surprise bill, contact EmblemHealth at the telephone number on the back of your ID card. You can also visit https://www.cms.gov/nosurprises for information about your rights under federal law.
For plans issued or renewed before January 1, 2022, you may qualify for an independent dispute resolution (IDR) under certain circumstances through New York State by submitting an IDR application to dispute the bill. To be eligible, services must be provided by a doctor at a hospital or ambulatory surgical center and you weren’t given certain required information about your care. For more information, visit the DFS website at https://dfs.ny.gov/consumers/health_insurance/surprise_medical_bills. If you qualify, you must complete an IDR Patient Application and send it to: New York State Department of Financial Services, Consumer Assistance Unit/IDR Process, One Commerce Plaza, Albany, NY 12257.