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Health Care Provider Rights

(Insurance Law Sections 3217-b, 3224-a, 3224-b, 4325, 4803 and Public Health Law Sections 4403, 4406-c & 4406-d)

Health Insurance Resource Center

The Insurance Law and Public Health Law include important protections for health care providers with respect to network participation, provider contracting, claims processing, and prompt payment for health care services. Some protections apply to all HMO and insurance coverage, while others apply only to HMO coverage and to managed care contracts offered by insurers (which most insurers do not offer).*

Participation in a Health Plan’s Network:

Provider Contracts:

Termination of Provider Contracts:

Non-renewal of a Participating Provider Contract:

Performance and Practice Information:

Patient Care and Treatment:

Claims Processing:

Overpayment Recovery Efforts:

Prompt Payment of Health Care Claims:

* Please note, a managed care contract offered by an insurer is defined as a contract which requires that all health care services be provided by a referral from a primary care provider and that services be rendered by a provider participating in the insurer’s network. In addition, in the case of an individual contract or a group contract covering no more than 300 lives, imposing a co-insurance obligation of more than 25% upon out-of-network services, which has been sold to five or more groups, a managed care contract also includes a contract which requires all services be provided pursuant to a referral from a primary care provider and that services provided pursuant to the referral be rendered by a participating provider in order for the member to obtain the maximum reimbursement.

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