N.Y. FIS Law § 605

§ 605. Dispute resolution for emergency services. (a) Emergency\nservices for an insured. (1) When a health care plan receives a bill for\nemergency services from a non-participating physician or hospital,\nincluding a bill for inpatient services which follow an emergency room\nvisit, the health care plan shall pay an amount that it determines is\nreasonable for the emergency services, including inpatient services\nwhich follow an emergency room visit, rendered by the non-participating\nphysician or hospital, in accordance with section three thousand two\nhundred twenty-four-a of the insurance law, except for the insured's\nco-payment, coinsurance or deductible, if any, and shall ensure that the\ninsured shall incur no greater out-of-pocket costs for the emergency\nservices, including inpatient services which follow an emergency room\nvisit, than the insured would have incurred with a participating\nphysician or hospital. If an insured assigns benefits to a\nnon-participating physician or hospital in relation to emergency\nservices, including inpatient services which follow an emergency room\nvisit, provided by such non-participating physician or hospital, the\nnon-participating physician or hospital may bill the health care plan\nfor the services rendered. Upon receipt of the bill, the health care\nplan shall pay the non-participating physician or hospital the amount\nprescribed by this section and any subsequent amount determined to be\nowed to the physician or hospital in relation to the emergency services\nprovided, including inpatient services which follow an emergency room\nvisit.\n (2) A non-participating physician or hospital or a health care plan\nmay submit a dispute regarding a fee or payment for emergency services,\nincluding inpatient services which follow an emergency room visit, for\nreview to an independent dispute resolution entity.\n (3) The independent dispute resolution entity shall make a\ndetermination within thirty days of receipt of the dispute for review.\n (4) In determining a reasonable fee for the services rendered, an\nindependent dispute resolution entity shall select either the health\ncare plan's payment or the non-participating physician's or hospital's\nfee. The independent dispute resolution entity shall determine which\namount to select based upon the conditions and factors set forth in\nsection six hundred four of this article. If an independent dispute\nresolution entity determines, based on the health care plan's payment\nand the non-participating physician's or hospital's fee, that a\nsettlement between the health care plan and non-participating physician\nor hospital is reasonably likely, or that both the health care plan's\npayment and the non-participating physician's or hospital's fee\nrepresent unreasonable extremes, then the independent dispute resolution\nentity may direct both parties to attempt a good faith negotiation for\nsettlement. The health care plan and non-participating physician or\nhospital may be granted up to ten business days for this negotiation,\nwhich shall run concurrently with the thirty day period for dispute\nresolution.\n (b) Emergency services for a patient that is not an insured. (1) A\npatient that is not an insured or the patient's physician may submit a\ndispute regarding a fee for emergency services, including inpatient\nservices which follow an emergency room visit, for review to an\nindependent dispute resolution entity upon approval of the\nsuperintendent.\n (2) An independent dispute resolution entity shall determine a\nreasonable fee for the services based upon the same conditions and\nfactors set forth in section six hundred four of this article.\n (3) A patient that is not an insured shall not be required to pay the\nphysician's or hospital's fee in order to be eligible to submit the\ndispute for review to an independent dispute resolution entity.\n (c) The determination of an independent dispute resolution entity\nshall be binding on the health care plan, physician or hospital and\npatient, and shall be admissible in any court proceeding between the\nhealth care plan, physician or hospital or patient, or in any\nadministrative proceeding between this state and the physician or\nhospital.\n (d) The provisions of this section shall not apply to hospitals that\nhad at least sixty percent of inpatient discharges annually which\nconsisted of medicaid, uninsured, and dual eligible individuals as\ndetermined by the department of health in its determination of safety\nnet hospitals.\n (e) For purposes of the hospital payment pursuant to subsection (a) of\nthis section, the amount the health care plan shall pay to the hospital\nshall be at least twenty-five percent greater than the amount the health\ncare plan would have paid for the claim had the hospital been in\nnetwork, based on the most recent contract between the health care plan\nand the hospital. Provided however, the amount paid by the health care\nplan pursuant to this subsection shall not prejudice either party or\npreclude either party from submitting a dispute to the dispute\nresolution entity relating to the payment to the hospital or preclude\nthe hospital from seeking additional payment from the health care plan\nprior to a decision by the dispute resolution entity. To the extent the\nprior contract between the hospital and health care plan expired greater\nthan twelve months prior to the payment of the disputed claim, the\npayment amount shall be adjusted based upon the medical consumer price\nindex. The provisions of this subsection shall only apply to the extent\nthe health care plan and hospital had previously entered into a\nparticipating provider agreement.\n