N.Y. Financial Services Law § 604

* § 604. Criteria for determining a reasonable fee. In determining the\nappropriate amount to pay for a health care service, an independent\ndispute resolution entity shall consider all relevant factors,\nincluding:\n (a) whether there is a gross disparity between the fee charged by the\nprovider for services rendered as compared to:\n (1) fees paid to the involved provider for the same services rendered\nby the provider to other patients in health care plans in which the\nprovider is not participating, and\n (2) in the case of a dispute involving a health care plan, fees paid\nby the health care plan to reimburse similarly qualified providers for\nthe same services in the same region who are not participating with the\nhealth care plan;\n (b) the level of training, education and experience of the health care\nprofessional, and in the case of a hospital, the teaching staff, scope\nof services and case mix;\n (c) the provider's usual charge for comparable services with regard to\npatients in health care plans in which the provider is not\nparticipating;\n (d) the circumstances and complexity of the particular case, including\ntime and place of the service;\n (e) individual patient characteristics;\n (f) the median of the rate recognized by the health care plan to\nreimburse similarly qualified providers for the same or similar services\nin the same region that are participating with the health care plan; and\n (g) with regard to physician services, the usual and customary cost of\nthe service.\n * NB Effective until August 26, 2026\n * § 604. Criteria for determining a reasonable fee. (a) In determining\nthe appropriate amount for a health care plan other than a health\nbenefit plan operated pursuant to article eleven of the civil service\nlaw to pay for a health care service, an independent dispute resolution\nentity shall consider all relevant factors, including:\n (1) whether there is a gross disparity between the fee charged by the\nprovider for services rendered as compared to:\n (A) fees paid to the involved provider for the same services rendered\nby the provider to other patients in health care plans in which the\nprovider is not participating, and\n (B) in the case of a dispute involving a health care plan, fees paid\nby the health care plan to reimburse similarly qualified providers for\nthe same services in the same region who are not participating with the\nhealth care plan;\n (2) the level of training, education and experience of the health care\nprofessional, and in the case of a hospital, the teaching staff, scope\nof services and case mix;\n (3) the provider's usual charge for comparable services with regard to\npatients in health care plans in which the provider is not\nparticipating;\n (4) the circumstances and complexity of the particular case, including\ntime and place of the service;\n (5) individual patient characteristics;\n (6) the median of the rate recognized by the health care plan to\nreimburse similarly qualified providers for the same or similar services\nin the same region that are participating with the health care plan; and\n (7) with regard to physician services, the usual and customary cost of\nthe service.\n (b) (1) In determining the appropriate amount for a health benefit\nplan operated pursuant to article eleven of the civil service law to pay\nfor a health care service, an independent dispute resolution entity\nshall select either the health care plan's payment or the\nnon-participating provider's fee depending on which one is closest to\nthe allowed benchmark, provided, however, that the independent dispute\nresolution entity may choose the health care plan's payment or the\nnon-participating provider's fee if it is not closest to the allowed\nbenchmark if:\n (A) the health care plan's payment or the non-participating provider's\nfee are equally distant from the allowed benchmark; or\n (B) the independent dispute resolution entity determines that any of\nthe following information submitted by either party clearly demonstrates\nthat the allowed benchmark is not appropriate:\n (i) the level of training, education and experience of the health care\nprofessional, and in the case of a hospital, the teaching staff, scope\nof services and case mix;\n (ii) the circumstances and complexity of the particular case,\nincluding time and place of the service; or\n (iii) individual patient characteristics.\n (2) If the independent dispute resolution entity selects the health\ncare plan's payment or the non-participating provider's fee that is not\nclosest to the allowed benchmark, such decision shall not be on the\nbasis of:\n (A) whether there is a gross disparity between the fee charged by the\nprovider for services rendered as compared to:\n (i) fees paid to the involved provider for the same services rendered\nby the provider to other patients in health care plans in which the\nprovider is not participating; or\n (ii) in the case of a dispute involving a health care plan, fees paid\nby the health care plan to reimburse similarly qualified providers for\nthe same services in the same region who are not participating with the\nhealth care plan;\n (B) the provider's usual charge for comparable services with regard to\npatients in health care plans in which the provider is not\nparticipating; or\n (C) with regard to physician services, the usual and customary cost of\nthe service.\n (3) If an independent dispute resolution entity makes a determination\npursuant to subparagraph (B) of paragraph one of subsection (b) of this\nsection, its written decision shall include an explanation of the\nfactors in subparagraph (B) of paragraph one of subsection (b) of this\nsection that demonstrated the health care plan's payment or\nnon-participating provider's fee closest to the allowed benchmark was\nmaterially different from the appropriate payment for the health care\nservice.\n (4) If the independent dispute resolution entity determines the\nnon-participating provider's fee is a reasonable fee for the services\nrendered, in no circumstances shall the amount owed by a health care\nplan exceed the maximum fee.\n (5) Notwithstanding the foregoing, disputes involving health care\nservices provided by a physician employed by a general hospital licensed\nunder article twenty-eight of the public health law or such hospital's\naffiliated medical school, or is part of a group practice that is\nestablished as a captive professional services corporation whose\nshareholders are employees of such hospital, shall be subject to\nsubsection (a) of this section even if paid for by a health benefit plan\noperated pursuant to article eleven of the civil service law.\n (c) No fee for services rendered shall be awarded pursuant to this\narticle:\n (1) if the health care plan can demonstrate that it has a contract\nwith the provider or a subsidiary or other entity owned or operated by\nthe provider that is in effect at the time the disputed service or\nservices were provided to provide the same service or services at the\nsame location; or\n (2) if the health care plan can demonstrate that a notice of\ndetermination for prior authorization has been issued to the patient's\nhealth care provider pursuant to section forty-nine hundred three of the\ninsurance law and section forty-nine hundred three of the public health\nlaw identifying the health care service or services in dispute as\nout-of-network, or, for patients covered by a health care plan not\nsubject to section forty-nine hundred three of the insurance law or\nsection forty-nine hundred three of the public health law, if a notice\nof determination for prior authorization has been issued to the\npatient's health care provider that includes all of the disclosures set\nforth in such laws and that clearly identifies the health care service\nor services in dispute as out-of-network.\n * NB Effective August 26, 2026 until August 26, 2031\n * § 604. Criteria for determining a reasonable fee. In determining the\nappropriate amount to pay for a health care service, an independent\ndispute resolution entity shall consider all relevant factors,\nincluding:\n (a) whether there is a gross disparity between the fee charged by the\nprovider for services rendered as compared to:\n (1) fees paid to the involved provider for the same services rendered\nby the provider to other patients in health care plans in which the\nprovider is not participating, and\n (2) in the case of a dispute involving a health care plan, fees paid\nby the health care plan to reimburse similarly qualified providers for\nthe same services in the same region who are not participating with the\nhealth care plan;\n (b) the level of training, education and experience of the health care\nprofessional, and in the case of a hospital, the teaching staff, scope\nof services and case mix;\n (c) the provider's usual charge for comparable services with regard to\npatients in health care plans in which the provider is not\nparticipating;\n (d) the circumstances and complexity of the particular case, including\ntime and place of the service;\n (e) individual patient characteristics;\n (f) the median of the rate recognized by the health care plan to\nreimburse similarly qualified providers for the same or similar services\nin the same region that are participating with the health care plan; and\n (g) with regard to physician services, the usual and customary cost of\nthe service.\n * NB Effective August 26, 2031\n