New York State Out of Network Services Mandate Takes Effect
This article outlines a mandate that recently went into effect. Please note that, due to our robust provider network, we do not anticipate many out of network referral requests.
The New York State Out of Network Mandate (the Mandate) took effect March 31, 2015. While the Mandate is fairly complex and includes a number of requirements, groups and members will likely be most impacted by the new rules around out of network referrals and surprise billing.
The Mandate applies to all insured products issued in New York State including HMO, POS, EPO, PPO, Traditional Indemnity, Child Health Plus and Individual Direct Pay products. This means that self-funded, Medicare Advantage/Supplemental and Federal Employee Program products are not affected by the Mandate.
Out of Network Referral Requests
The Mandate stipulates that if a member is referred to a nonparticipating provider because a participating provider with the appropriate training and experience is not available, and the Health Plan denies the referral request, the member has the right to request an in network benefit review. HMO and POS members have this right today; the Mandate now extends this right to comprehensive products with an out of network benefit, such as PPO products.
If a health plan approves the referral, the out of network claim will be processed under the member’s in network benefit, and the member will be held harmless from being balance-billed by the non-participating provider. The member will still be responsible for any applicable cost-share under their in network benefit.
When a referral request is denied, the Health Plan must provide the member a list of qualified, participating physicians. If the member’s physician submits a certification to the Health Plan that none of the listed providers has the necessary training and experience, but a non-participating provider does have the relevant training and experience, then the Health Plan must conduct a utilization review of the referral denial. If the Health Plan upholds the denial, the member will receive a final adverse determination, which will give the member the right to seek an external appeal of the Health Plan’s decision.
The member may appeal the Health Plan’s decision; if the denial is upheld, the member may file an external appeal.
The Mandate defines a ‘surprise bill’ as a bill the member receives for healthcare services, other than emergency services, under the following situations:
- Services rendered by a nonparticipating physician at a participating hospital or ambulatory surgical center where a participating provider is not available, a non-participating physician renders services without the member’s knowledge, or unforeseen medical services arise at the time healthcare services are rendered;
- Services rendered by a nonparticipating referred health care provider when the member was referred to the nonparticipating physician by a participating provider.
These situations occur without the member’s prior knowledge of the provider’s participation status or the opportunity to refuse or request a participating provider.
For services meeting the definition of a “surprise bill” under the Mandate, members must be held harmless from such bills rendered by New York State providers. Services rendered outside New York State are not eligible for coverage under the surprise bill rules.
Surprise bills are identified post service. As a result, the member’s explanation of benefits and monthly health summary will be flagged if a claim processes with a high probability of being a surprise bill. The message on the EOB or monthly health summary will provide an explanation of what a surprise bill is, and will instruct the member to call Customer Care with questions.
Members who believe that a surprise bill situation exists should complete an Assignment of Benefit (AOB) form and submit it to both the provider and the Health Plan. This form indicates that the member is assigning benefits to the provider and any additional payment, if warranted, would be issued to the provider.
The Health Plan will review the Assignment of Benefit form and the applicable claim information in order to determine whether a surprise bill scenario exists. If the Health Plan determines that the claim meets the definition of a surprise bill, it will then determine if a reasonable amount has been paid for the claim. The Health Plan may make an additional payment to the provider. Any payment disputes will be reviewed by a certified Independent Dispute Resolution Entity who will issue a binding decision.
Members may obtain information regarding surprise bills or an Assignment of Benefit form, or submit a claim, on our website.
AOB form in the Submit a Claim section (PDF) | Frequently Asked Questions | Submit a claim