Consumer and Provider Rights and Responsibilities

Related Laws: Insurance Law Sections 3217-a & 4324 and Public Health Law Section 4408

HMOs and insurers (health plans) subject to NY law (coverage that is not self-insured) must give you the following information. It will be in your insurance policy or in a separate document. You also have the right to request this information from any health plan if you are shopping for coverage:

Health Care Coverage:

• A description of the benefits, limits, and exclusions.
• The definition of medical necessity.
• Which health care services require you to get authorization in advance from your health plan and how to request authorization.

Your Financial Responsibility:

• Your responsibility for payment of premiums, coinsurance, co-payments, and deductibles.
• Any caps on payments for services and your financial responsibility for services that aren't covered.
• Your responsibility for payment when a provider is not part of your health plan's network.
• If you have out-of-network coverage:
  • How your health plan pays for out-of-network services.
  • How your health plan's payment compares to the usual cost of out-of-network services.
  • Examples of costs for certain out-of-network services.
  • How you can estimate what you will have to pay for out-of-network services.

The Grievance Procedure, including:

• The right to file a grievance for denials of referrals or because a benefit is not covered under your contract.
• The right to file a grievance orally.
• The toll-free number to use to file a grievance.
• The timeframes for determinations.
• How to appeal a grievance determination.
• Your right to pick someone to help you with your grievance.

The Utilization Review Procedure when services are denied as not medically necessary, experimental or investigational, a clinical trial or a rare disease treatment including:

• The toll-free number for you to use.
• The timeframes for determinations.
• Notice that all denials will be made by medical personnel and will include the medical reason.
• How to appeal, including the timeframes.
• Notice of your right to an independent external appeal.
• Your right to pick someone to appeal for you.

Access to Care:

• Emergency Services. How to get emergency services and that prior authorization cannot be required.
• Selecting Providers. How to get services from your health plan providers, including how to tell if a provider is accepting new patients and how to change providers.
• OB/GYN Services. Notice that you do not need a referral for obstetric and gynecologic services.
• Out-of-Network Referrals. Notice that you may get a referral to an out-of-network provider when your health plan does not have an in-network provider with the training and experience to meet your health care needs, and how to request an out-of-network referral.
• Standing Referrals. Notice that you may request a standing referral to a specialist if you need ongoing care.
• Continued Care For New Health Plan. Notice that if you are a new health plan member and your provider does not participate, you may continue a course of treatment with the non-participating provider for up to 60 days if you have a life-threatening or disabling condition, or through your pregnancy if you are in the second trimester.
• Continued Care When Your Provider Leaves Network. Notice that if your provider leaves your health plan's network, you may continue a course of treatment for up to 90 days or through your pregnancy if you are in the second trimester.
• Provider Directory. Your health plan must provide a listing by specialty, of the name, address, and telephone number of all participating providers and facilities. It must also include doctor board certification information, languages spoken and any affiliations with participating hospitals. The listing must be posted on your health plan's website. The listing must be updated within 15 days of the addition or termination of a provider from your health plan's network or a change in a doctor's hospital affiliation.

Contacting Your Health Plan:

• Your health plan must give you its address and telephone number.
• Your health plan must describe how you can submit a claim for health care services. Health plans must accept claims submitted online, by email, or by fax.
• Your health plan must describe how it meets the needs of non-English speaking members.
• Your health plan must provide a description of how you can participate in the development of its policies.

Health plans must give you the following information if you ask for it, including if you are shopping for coverage:

• Officers & Directors. The names, addresses, and positions of the board of directors and officers of your health plan.
• Financial Statement. Your health plan's most recent annual financial statement.
• Individual Contracts. The most recent individual direct payment subscriber contracts.
• Complaints. Information about consumer complaints.
• Confidentiality. How your health plan protects the confidentiality of medical records.
• Drug Formularies. Drug formularies used by your health plan, including whether individual drugs are covered.
• Quality Assurance. A description of your health plan's quality assurance program, if any.
• Experimental or Investigational. How decisions are made that a treatment is experimental or investigational.
• Hospital Affiliations. Participating provider affiliations with hospitals.
• Clinical Review Criteria. Clinical review criteria relating to a particular disease.
• Provider Applications. The application procedures and necessary qualifications for providers to participate in your health plan's network.
• Provider Network Status. Whether a certain provider is in-network.
• Out-of-Network Payment. The approximate dollar amount your health plan will pay for an out-of-network service.

If your HMO has not provided this information either upon your enrollment or request, you should submit a complaint to the New York Department of Health, Office of Health Insurance Programs, Bureau of Consumer Services - Complaint Unit, Corning Tower - OCP Room 1609, Albany, New York 12237; or call (800) 206-8125; or email [email protected].

Related Laws: Public Health Law Section 24

Doctors and other providers must give you information about which health plan networks they are in, the amount they will charge you for services, the hospitals where they could admit you, and the other providers they may schedule to treat you. See Information Your Doctor and Other Health Care Professionals Must Give You.

Related Laws: Public Health Law Section 24

Hospitals must post on their websites: Their charges or how to get the information, which health plan networks they are in, and information about the doctors that could treat you in the hospital.

Hospitals must, in registration or admission materials that they give you before non-emergency hospital services: Tell you to check with your doctor arranging your hospital services to find out if your doctor is scheduling other providers to treat you and how to find out if they are in-network. See Information Your Hospital Must Give You.

Related Laws: Insurance Law Sections 3217-a, 3217-b, 3217-d, 3241, 4306-c, 4324, 4325 & 4804 and Public Health Law Sections 4403 & 4408)

Right to Go Out-of-Network When Your Health Plan Does Not Have An In-Network Provider:

• You may get a referral or authorization to an out-of-network provider when your health plan does not have an in-network provider with the appropriate training and experience to meet your health care needs. This will be at no additional cost beyond what you would pay to see an in-network provider.
• Contact your health plan to receive information on how to get a referral or authorization to an out-of-network provider.

Choice of Primary Care Doctor:

• If you have health insurance coverage that requires you to pick a primary care provider (PCP), you can pick any available in-network PCP.
• If you have a life-threatening or degenerative and disabling condition and you need ongoing specialty care, you may request that your specialist coordinate your care, instead of your PCP. Health plans that require referrals must have procedures to allow you to make this request.

Specialty Care:

• You have the right to request a standing referral to a specialist or specialty care center if you require ongoing specialty treatment and your health plan requires referrals.

When Your Provider Is Not In Your New Health Plan’s Network:

• If you enroll in a new health plan and your provider is not in-network, you may continue a course of treatment with your provider for up to 60 days if you have a life-threatening or disabling condition, or through your pregnancy if you are in the second trimester. Your provider must agree to accept reimbursement from your health plan as payment in full.

When Your Provider Leaves Your Health Plan's Network:

• If your provider leaves the network of your health plan, you may continue a course of treatment for up to 90 days or through your pregnancy. You only have to pay your in-network cost-sharing (copayment, coinsurance, and deductible). Your provider must accept reimbursement from your health plan at the previously agreed to rate as payment in full, except for your in-network cost-sharing.  

Network Adequacy:

• Health plans must have a network of providers adequate to meet the needs of members.

Gag Clauses:

• Health plans may not prohibit your doctor from discussing all treatments for a medical condition with you.

Related Laws: Insurance Law Sections 3216, 3221, 3241(c), 4303, 4900, 4902 & 4905, Financial Services Law Article 6 and Public Health Law Sections 4900, 4902 & 4905

• Definition of Emergency Condition. Emergency room visits are covered based on the "prudent layperson standard." Under the prudent layperson standard, an emergency condition means:
  • A medical or behavioral condition that is acute and includes severe pain.
  • If you do not get immediate medical attention it will:
    • Put your health in serious jeopardy;
    • If you are pregnant, put the health of your unborn child in serious jeopardy;
    • In the case of a behavioral condition, put your health or the health of others in serious jeopardy;
    • Cause serious impairment to your bodily functions;
    • Cause serious dysfunction of a bodily organ; or
    • Cause serious disfigurement.
• No Prior Approval. Your health plan cannot require that you seek prior approval for emergency care.
• Health Plans Must Cover Emergency Services. Your health plan must protect you from bills for out-of-network emergency services in a hospital. You are only responsible for paying your in-network cost-sharing (copayment, coinsurance and deductible) for out-of-network emergency services, including inpatient services that follow an emergency room visit. Let your health plan know if you receive a bill from an out-of-network provider for emergency services that is more than your in-network cost-sharing.
• Providers Must Only Bill In-Network Cost-Sharing. Your provider can only bill you for your in-network copayment, coinsurance, or deductible for emergency services, including inpatient services which follow an emergency room visit.

Related Laws: Financial Services Law Article 6

How to Protect Yourself From Surprise Bills If You Have HMO or Insurance Coverage Subject to NY Law (coverage that is not self-insured).

You are protected from surprise bills 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.

Learn more about Surprise medical bills and the New York IDR process.

(Insurance Law Sections 3216, 3217-a, 3221, 4303, 4306-b & 4322 and Public Health Law Section 4406-b)

HMOs and insurers (health plans) that provide comprehensive health insurance coverage that is subject to NY law (coverage that is not self-insured) are required to cover the following services. (You should check your health insurance policy for the terms and conditions of your coverage.)

• OB/GYN Services. Women do not have to get a referral for OB/GYN services for annual examinations, care resulting from the annual examinations, treatment of acute gynecologic conditions, and any care related to a pregnancy.
• Bone Mineral Density. Coverage for bone mineral density measurements and testing.
• Cancer Screenings. Coverage for cervical cancer screening and breast cancer screening (mammograms). Cost-sharing also doesn’t apply to other screening and diagnostic imaging to detect breast cancer, including ultrasounds, MRIs, and 3D mammograms.

• Contraceptives. Coverage for contraceptive drugs, devices and products, although religious employers may ask for a contract without contraceptive coverage and their employees may purchase the coverage directly from the health plan. Health plans must cover these contraceptives without cost-sharing:

  • Contraceptive drugs, devices or products;
  • Emergency Contraceptives, including over-the-counter ones;
  • Over-the-counter contraceptives;
  • Voluntary sterilizations;
  • Patient education and counseling on contraceptives; and
  • Follow-up services related to contraceptives, including, management of side effects, counseling for continued adherence, and device insertion and removal.

  You can get a 12-month supply of contraceptives dispensed at the same time. Your health plan doesn’t have to cover all contraceptives on their formulary so long as each different kind of drug is covered. You can ask your health plan to cover a contraceptive not on their formulary if the covered contraceptive is not available or is deemed medically inadvisable. Your health care provider should complete a Contraceptive Exception Request Form and send it to your health insurer.

• Mastectomy Coverage. Coverage for a mastectomy. After a mastectomy, a woman has the right to stay in the hospital until she and her doctor decide it is medically appropriate for her to go home.
• Breast Reconstruction. Reconstructive surgery after a mastectomy on the breast on which the mastectomy has been performed and on the other breast to produce a symmetrical appearance, breast prosthetics, and treatment of lymphedemas.
• Maternity Care. A new mother has the right to remain in the hospital for 48 hours after delivery and at least 96 hours after a Caesarean section. If the mother decides to leave the hospital earlier, she is entitled to one home health care visit. Coverage for educational programs for new mothers in the hospital is also required. New moms also get coverage without cost-sharing for breastfeeding support, counseling, and supplies, including the rental or purchase of a breast pump, for the entire time the mom is breastfeeding.
• Infertility. Basic infertility services (for example, tests to determine the cause of infertility ) are covered. Comprehensive infertility services (including artificial insemination) are also covered. Some exclusions may apply to infertility benefits, including in vitro fertilization (IVF), gamete intrafallopian tube transfer (GIFT) and zygote intrafallopian tube transfers (ZIFT) for individual and small group coverage.
  • IVF Coverage for Large Groups. Large group coverage (for employers that have 101 or more employees) must cover three (3) IVF cycles.
  • Fertility Preservation. Coverage for fertility preservation services for individuals having treatment or surgery that will affect their fertility (for example, chemotherapy or other cancer treatments) is also covered for individual, small and large group coverage.
  • No Discrimination. When deciding when to cover infertility benefits, health plans are prohibited from discriminating based on a person’s expected length of life, present or predicted disability, degree of medical dependency, perceived quality of life or other health conditions, or personal characteristics, including age, sex, sexual orientation, marital status, or gender identity.

Related Laws: Insurance Law Sections 3217-d(a), 4306-c(a), 4802 & Article 49 and Public Health Law Section 4408-a & Article 49

HMOs and insurers (health plans) subject to NY law (coverage that is not self-insured) are required to have a grievance procedure (for contractual denials) and a utilization review procedure (for medical denials) for you to use to appeal their determinations.

Grievance Procedure

• A Grievance Is a Complaint You Send to Your Health Plan when:
  • A benefit is denied because it is not covered under your health insurance contract for other than medical necessity reasons.
  • You are denied a referral to a requested provider.
  • You have a complaint concerning any plan determination other than a medical necessity, experimental or investigational treatment, clinical trial or rare disease treatment for which the utilization review procedure is to be used.
• File By Phone. You have the right to file grievances by phone for benefit determinations or referrals, and health plans are required to have a toll free hotline for grievance calls.
• Timeframe For You To Send A Grievance. You have 180 days to send a grievance to your health plan from the date of denial or decision.
• Timeframes For Grievance Decisions. Your health plan is required to make a decision upon receipt of your grievance or grievance appeal in the following timeframes:
  • Urgent. 72 hours for urgent care.
  • Pre-Service. 15 days if you didn't receive the care yet.
  • Post-Service. 30 days if you received the care.
  • All Others. 60 days (or if an appeal, 30 business days of receipt of information).
• Grievances for Out-of-Network Service Denials. You may have your grievance for an out-of-network service treated as a medical denial (utilization review appeal) and subject to an independent external review if:
  • Your health plan said the out-of-network service is not materially different from a service that can be provided in-network; and
  • Your doctor submits a written statement to your health plan that the out-of-network service is materially different from the health service the health plan approved; and
  • Your doctor provides two documents of medical evidence that: (1) the out-of-network service is likely to be more clinically beneficial to you than the in-network service your health plan recommended; and (2) the risk would not be increased over the in-network health service.
• Grievances for Out-of-Network Referral Denials. You may have your grievance for a referral to an out-of-network provider treated as a medical denial (utilization review appeal) and subject to an independent external review if:
  • You requested a referral to an out-of-network provider because your health plan did not have an in-network provider with the training and experience to meet your health care needs who is able to provide the requested health care service; and
  • Your doctor submits a written statement to your health plan that the in-network providers recommended by your health plan do not have the training and experience to meet your health care needs; and
  • Your doctor recommends an out-of-network provider with the appropriate training and experience to meet your health care needs who is able to provide the requested service.
  • Learn how to file an External Appeal.

Utilization Review Procedure for Decisions on Medical Care

You can also appeal any denial of care that your HMO or insurer (health plan) decides is not medically necessary, experimental or investigational, a clinical trial or a rare disease treatment (utilization review decisions).

• Learn more about filing an External Appeals.

Timeframes For Utilization Review Decisions. Your health plan is required to make decisions in the following timeframes:

• Urgent. Within 72 hours.
• Pre-Service. Generally within 3 business days for care you have not received yet. If your health plan needs information, it must ask for it within 3 business days. You and your provider have 45 days to send the information. Your health plan must make a decision within 3 business days of receiving the information or 15 days after the end of time you had to send the information.
• Concurrent. Generally within 1 business day for care you are currently receiving. If your health plan needs information, it must ask for it within 1 business day. You and your provider have 45 days to send the information. Your health plan must make a decision within 1 business day of receiving the information or 15 days after the end of time you had to send the information.
• Post-Service. Generally within 30 days for care you received. If your health plan needs information, it must ask for it within 30 days. You and your provider have 45 days to send the information. Your health plan must make a decision within 15 days of receiving the information or within 15 days after the end of time you had to send the information.

Clinical Peer Reviewers. You have the right to have a medical necessity denial (including denials because a service is experimental or investigational, a clinical trial or a rare disease treatment) made by medical professionals.

• Timeframe For You to Appeal A Utilization Review Denial. You have 180 days to appeal a utilization review denial with your health plan from the date of denial.

• Timeframes For Utilization Review Appeal Decisions. When you appeal, your health plan is required to make utilization review appeal decisions in the following timeframes:

  • Urgent. Within 72 hours.
  • Pre-Service. Within 30 days if one level of appeal and 15 days if two levels of appeal.
  • Post-Service. Within 60 days if one level of appeal and 30 days if two levels of appeal.

  Right To External Appeal. If your health plan upholds a denial based on medical necessity, an experimental or investigational treatment, a clinical trial, a rare disease treatment, an out-of-network service (if your doctor submitted the required information to your health plan), or an out-of-network referral (if your doctor submitted the required information to your health plan) you have a right to an external appeal.

If you need assistance with a preauthorization request, complaint, grievance, or appeal with your health insurer, you can designate a person or persons or organization to assist you by completing the form and submitting it to the address or fax number on your member identification card or other method specified by your insurer.

Any Willing Provider. New York does not have a willing provider law and HMOs and insurers are not required to accept any provider who wishes to join their network.

Network Adequacy. HMOs and insurers are required to maintain a provider network that is sufficient to meet the health needs of insureds and provide an appropriate choice of provider.

Network Application and Qualification. MOs and insurers offering a managed care plan are required to make available, upon request, written application procedures and minimum qualification requirements that a healthcare professional is required to meet to be considered for participation in the health plan's network.

Credentialing of Providers. HMOs and insurers offering a managed care plan are required to complete review of a healthcare professional's application to participate in their network within 90 days.

Notification. HMOs and insurers offering a managed care plan are required to notify the health care professional as to whether the health care professional is credentialed or not, or if additional time is needed in spite of the health plan's best efforts or because the health plan is waiting for additional information from a third party. The health plan is also required to make every effort to obtain the information as soon as possible.

Timeframe. If an incomplete health care professional application is received, or if the HMO or insurer offering a managed care plan is not currently accepting additional health care professionals of the applicant's type, the health plan should respond to the health care professional with such notice as soon as possible, but no later than 90 days from receipt of the application.

Provisionally Credentialed. Health Care Professionals Joining a Group Practice. A health care professional who is newly-licensed or has relocated to New York and has not previously practiced in New York can be "provisionally credentialed" if the health care professional joins a group practice of health care professionals that participates with a health plan, submits a completed credentialing application, and does not receive a response to the application within 90 days. The provisionally credentialed health care professional is considered a participating provider as of the day following the 90th day of the health plan's receipt of the completed application and until the health plan issues a determination on the credentialing application. The group practice is required to notify the health plan in writing that if the credentialing application is denied, the group practice or the health care professional will: (1) refund any payments made for in-network services that exceed the insured's out-of-network benefits; and (2) not pursue the insured for any payments that exceed the insured's in-network cost-sharing.

• The provisionally credentialed health care professional may not be designated as a primary care physician until he or she is fully credentialed.
• Interest and penalties under the Prompt Pay Law do not apply to claim denials submitted during the provisionally credentialed period, but nothing prevents a health plan from paying a claim for a provisionally credentialed health care professional.
• A health plan may not deny a claim upon appeal for services provided by a provisionally credentialed health care professional solely based on the ground that the claim was not timely filed.

Provisionally Credentialed Physicians Employed by Facilities. For physician credentialing applications received on or after July 1, 2020, a physician who is:

• newly licensed or has relocated to New York and has not previously practiced in New York; OR
• has changed his or her corporate relationship so that it results in a new tax ID number and who previously had a participating provider agreement with the health care plan immediately prior to the change;

AND the physician becomes employed by a general hospital or diagnostic treatment center licensed under Public Health Law Article 28, or a facility licensed under Mental Hygiene Law Articles 16, 31 or 32 that participates with a health plan and whose other employed physicians participate with the health care plan, can be "provisionally credentialed” upon the health plan’s receipt of the physician’s and facility’s completed portions of the heath plan’s credentialing application and the health plan being notified in writing that the physician has been granted hospital privileges.

• The health plan will pay the facility once the physician is fully credentialed with the health plan for the services provided by the provisionally credentialed physician for up to 60 days after the completed application is submitted.
• If the physician is not credentialed, the health plan is not responsible for paying for the services. The facility is not permitted to pursue reimbursement from the insured except to collect the in-network copayment, coinsurance or deductible.
• The provisionally credentialed physician may not be designated as a primary care physician until he or she is fully credentialed.

Required Provider Contract Provisions. HMOs and all insurers are required to include the following items in participating provider contracts:

• Payment Calculation. The method by which payments to the provider will be calculated, including any retrospective or prospective adjustments;
• Time Periods. The time periods within which calculations will be completed, the dates payments and adjustments will be due, and the dates upon which payments and adjustments will be made;
• Information Relied Upon. A description of the information relied upon to calculate payments or adjustments, and how a provider can access a summary of the calculations or adjustments;
• Dispute Process. The process to resolve disputed, incorrect or incomplete information, and the process to adjust payments which were made using the incorrect or incomplete information; and
• Arbitration. The right of either party to seek arbitration under Article 75 of the Civil Practice Laws and Rules for disputes regarding payment terms of the contract.

Liability. HMOs and insurers cannot transfer liability to the provider (other than a medical group for HMOs) for activities, actions or omissions of the health plan.

Financial Risk. HMOs and insurers cannot transfer financial risk to providers in a manner inconsistent with Public Health Law Section 4403(1)(c) or penalize providers for unfavorable case mix so as to jeopardize the quality of or the insured's appropriate access to medically necessary services.

Adverse Reimbursement Change. HMOs and insurers are required to give health care professionals at least 90 days written notice before implementing a contract change that could have a material adverse impact on the provider's aggregate level of payment, unless such change is otherwise required by law or required because of changes in fee schedules, reimbursement methodology or payment policies established by a government agency or the American Medical Association's current procedural terminology (CPT) codes, reporting guidelines and conventions, or is expressly provided under the terms of the contract. If the health care professional objects to the change, the health care professional may give written notice to terminate the contract within 30 days of the date of notice of the change, and termination will be effective on the implementation date of the change.

Hospital Emergency Admissions. HMOs and insurers are not permitted to deny payment to a hospital for a claim for medically necessary inpatient services resulting from an emergency admission solely because the hospital did not timely notify such insurer that the services had been provided. HMOs, insurers and hospitals may agree to requirements for timely notification of medically necessary inpatient services resulting from an emergency admission and to reduction in payment for failure to timely notify, provided that:

• Any requirement for timely notification provides for a reasonable extension of timeframes for emergency services provided on weekends or federal holidays;
• Any agreed to reduction in payment for failure to timely notify does not exceed $2,000 or 12% of the payment amount due for the services, whichever is less; and
• Any agreed to reduction in payment for failure to timely notify shall not be imposed if the hospital could not determine, after reasonable efforts, the patient's insurance coverage at the time the inpatient services were provided.

Explanation of Reasons. HMOs and insurers offering a managed care plan cannot terminate a participating health care professional's contract unless the health plan gives the health care professional a written explanation of the reasons for the proposed contract termination and an opportunity for a review or hearing. This requirement does not apply in cases of imminent harm to patient care, a determination of fraud, or a final disciplinary action by a state licensing board that impairs the provider's ability to practice.

Notice Requirements. HMOs and insurers offering a managed care plan are required to include the following in a notice of a proposed contract termination:

• The reasons for the proposed action;
• Notice that the health care professional has the right to request a hearing or review, at the health care professional's discretion, before a panel appointed by the health plan;
• A time limit of not less than 30 days within which the health care professional may request the hearing; and
• A time limit for a hearing date which is required to be held within not less than 30 days after the date the hearing was requested.

Hearings. HMOs and insurers offering a managed care plan are required to adhere to the following requirements with respect to any hearing:

The hearing panel is required to be made up of three persons appointed by the health plan. At least one member of the panel is required to be a clinical peer reviewer in the same discipline and the same or similar specialty as the health care professional under review. The panel may consist of more than three persons however one third are required to be clinical peers.

The hearing panel is required to render a timely decision. Decisions shall include reinstatement of the health care professional, provisional reinstatement of the provider subject to conditions, or termination. Decisions are required to be in writing.

A hearing panel's decision to terminate the health care professional will be effective at least 30 days after the health care professional receives the decision. However, the termination cannot be effective earlier than 60 days from the receipt of the notice of termination.

Hospital Cooling Off Period. If a contract between an HMO or insurer and a hospital is not renewed or is terminated by either party, the parties are required to continue to abide by the terms of the contract for two months from the date of termination or, in the case of a non-renewal, from the end of the contract period. Within 15 days after the commencement of the two month period, notice is required to be provided to all potentially affected insureds. This requirement does not apply when both parties mutually agree in writing to the termination or non-renewal and the HMO or insurer provides notice to the insured at least 30 days before the termination. The Department of Health can also waive the two-month period upon the request of either party to a contract that is being terminated for cause.

Non-renewal of a Participating Provider Contract. Either the health plan or the health care professional may exercise the right of non-renewal at the expiration of an HMO contract or a managed care contract offered by an insurer. If no express expiration date is given, either the health care professional or the health plan can exercise the right of non-renewal each January 1st upon 60 days’ notice to the other party. A non-renewal is not considered a termination and no appeal rights are granted.

Evaluation Information. HMOs and insurers offering a managed care contract are required to develop policies and procedures to ensure that participating health care professionals are regularly informed of the information maintained by the health plan to evaluate the performance or practice of health care professionals.

Provider Profiling. HMOs and insurers offering a managed care contract are required to consult with health care professionals when developing methodologies to collect and analyze provider profiling data.

Profiling Data. Any profiling data used by an HMO or insurer offering a managed care contract to evaluate health care professionals is required to be measured against stated criteria and an appropriate group of participating health care professionals using similar treatment modalities serving comparable patient populations.

Opportunity to Discuss. Health care professionals have to be given the opportunity to discuss the unique nature of the health care professional's patient population which may have a bearing on the provider's profile and to work cooperatively with the HMO or insurer offering a managed care contract to improve the health care professional's performance.

Impermissible Termination. No HMO or insurer offering a managed care contract may terminate or refuse to renew a participating health care professional's contract solely because the health care professional has:

• Advocated on behalf of a patient.
• Filed a complaint against the health plan.
• Appealed a decision of the health plan.
• Provided information or filed a report with an appropriate government body regarding the health plan's actions.

Reasons for Termination. No participating health care professional contract with an HMO or insurer offering a managed care contract may contain provisions which supersede or impair the health care professional's right to a notice of reasons for the termination and an opportunity for a hearing.

Treatment Information. HMOs and insurers cannot restrict a provider from telling their patient:

• All treatments available for the patient's condition, including treatments that may not be covered by the health plan.
• The provisions or terms of the patient's health plan as they relate to the patient.

Filing Complaints. HMOs and insurers cannot restrict a provider from filing a complaint to an appropriate governmental body regarding policies or procedures the provider believes may negatively impact the quality of care or access to care.

Patient Advocacy. HMOs and insurers cannot prohibit or restrict a provider from advocating on behalf of a patient for coverage of a particular treatment.

Accept Claims. HMOs and insurers are required to accept and initiate the processing of all health care claims submitted by physicians that are consistent with the current version of the American Medical Association's CPT codes, reporting guidelines and conventions and the centers for Medicare and Medicaid services (CMS) health care common procedure coding system (HCPCS).

Claim Denials Reasons. HMOs and insurers may determine that a claim is not eligible for payment, in full or in part, based on a determination that:

• The claim is not complete;
• The service provided is not a covered benefit under the contract or policy;
• The insured did not obtain a referral or pre-certification or satisfy any other condition precedent to receive covered benefits from the physician;
• The covered benefit exceeds the benefit limits of the contract or agreement;
• The person is not eligible for coverage or is otherwise not compliant with the terms and conditions of his or her contract;
• Another HMO or insurer is liable for all or part of the claim; or
• The plan has a reasonable suspicion of fraud or abuse.

Claims Software. HMOs and insurers are required to provide the name of the commercially available claims editing software product that the health plan utilizes and any significant edits on their provider websites and in provider newsletters. Health plans are also required to provide such information upon the written request of a participating physician.

Claim Submission. HMOs and insurers are required to accept claims submitted in writing, including through the internet, by e-mail or by fax.

Time to File Claims. Providers are required to submit health care claims within 120 days after the date of service for the claims to be valid and enforceable against HMOs and insurers, unless the parties agree to a time period that is more favorable to the provider. (Providers are required to submit claims within 90 days after the date of service for Medicaid managed care plans.)

Promptly Pay Claims. HMOs and insurers are required to pay claims for health care services within 30 days of receipt if the claims are submitted through the internet or by e-mail and within 45 days of receipt if the claims are submitted on paper or by fax, except in cases where the obligation to make payment is not reasonably clear or there is evidence that the bill may be fraudulent.

Obligation To Pay. If the obligation to pay is not reasonably clear, an HMO or insurer shall pay any undisputed portion of the claim and either notify the member or provider, in writing, within 30 calendar days of the receipt of the claim that the health plan is not obligated to pay and the reasons, or request additional information needed to determine liability to pay the claim or make the payment.

Timeframe. Upon receipt of the information requested, or an appeal of a claim for the denied health care services, an HMO or insurer shall comply with the 30 or 45-day requirement for clean claims.

Reconsideration. Participating health care providers may request reconsideration of a claim that is denied solely because it was untimely submitted. If the provider can demonstrate that his or her non-compliance was a result of an unusual occurrence and that he or she has a pattern or practice of timely submitting claims, the HMO or insurer is required to pay such claim, but may reduce the reimbursement due by up to 25% of what the HMO or insurer would have paid had the claim been timely submitted.

Hospital Claims. Within 30 days of receipt of payment of a claim for which payment has been adjusted based on a particular coding to a patient, a hospital has the opportunity to submit the affected claim with medical records supporting the hospital's initial coding of the claim. Upon receipt, the HMO or insurer is required to review such information to ascertain the correct coding for payment and process the claim in accordance with the timeframes set forth above. If the HMO or insurer processes the claim consistent with its initial determination, it is required to provide a statement with the decision explaining why the initial adjustment was appropriate. If the HMO or insurer increases the payment based on the information submitted by the hospital, but fails to do so within the required timeframes, it is required to pay interest on the amount of such increase at the rate set by the commissioner of taxation and finance for corporate taxes, computed from the end of the 45-day period after resubmission of the additional medical record information.

Violation. Each claim or bill processed after the 30 or 45-day time period is a separate violation.

Payment of Interest. For any violation of the prompt payment law, interest is due. Interest is calculated as the greater of: 12% per annum or the rate set by the commissioner of taxation and finance for corporate taxes pursuant to New York Tax Law Section 1096(e)(1). Interest is calculated from the date the claim or health care payment was required to be made. When the amount of interest due is less than two dollars, the HMO or insurer is not required to pay the interest.

File a Prompt Payment Complaint

The Department of Financial Services investigates insurance complaints involving licensed insurance entities. This Department cannot act as your lawyer, give legal advice, recommend, or rate insurers.

Before contacting us regarding an alleged prompt pay violation, please do the following:

• Contact the insurer or HMO to verify that the claim was received.
• Determine the type of coverage. If the patient is covered by a self-funded plan or Medicare, DFS lacks jurisdiction to assist.
• Review your records to ensure the claim has not been paid or denied.
• If the insurer or HMO has requested additional documentation and you have not supplied it, the claim is not delinquent and should not be submitted as a complaint.

You can file a No Fault, Workers Compensation or Prompt Pay Complaint online via the secure DFS Portal.

You will receive immediate confirmation and be assigned a file number.

You will have 30 minutes to process the complaint form. If you do not complete the form within 30 minutes you will be prompted to refresh and the information you have entered before refreshing will be lost.

To get started, visit the DFS portal:

DFS Portal

Notice. Other than recovery for duplicate payments, HMOs and insurers are required to give providers 30 days‘ notice before engaging in overpayment recovery efforts. The notice is required to include:

• The patient's name;
• Service date;
• Payment amount;
• Proposed adjustment; and
• A reasonably specific explanation of the proposed adjustment.

Opportunity to Challenge. HMOs and insurers are required to give providers the opportunity to challenge an overpayment recovery and are required to establish written policies and procedures for providers to follow when challenging the recovery. Any such challenge is required to set forth the specific grounds for the challenge.

Time Limit for Starting Overpayment Recoveries. HMOs and insurers are only permitted to initiate overpayment recovery within 24 months of the date the original payment was received by the provider, except in cases involving fraud, intentional misconduct, abusive billing or when initiated at the request of a self-funded plan, required by a federal or state government program or coverage that is provided by the State or a municipality to its employees, retirees or members.

Offsets. If a provider asserts underpayment of a claim, the HMO or insurer may defend or offset the assertion by overpayments that were made within the timeframe extending as far back as to the underpayment in question. If the underpayment is confirmed, the HMO or insurer may lessen or balance the amount owed to the provider by identifying an amount the HMO or insurer overpaid to the provider from the time of the underpayment to the present. However, the HMO or insurer may not collect overpayments in excess of the provider underpayment, unless the overpayment occurred within the last 24 months or an exception applies as described above.

Patient Billing. An out-of-network provider is prohibited from billing a patient for any amount other than the patient's in-network cost-sharing (copayment, coinsurance, or deductible) for a surprise bill. Learn more about surprise medical bills.   

Surprise Bill Certification Form. An out-of-network provider may ask their patient to sign a Surprise Bill Certification Form at the time that services are rendered.  The out-of-network provider must send a copy to the  patient’s health plan.  For services provided at an in-network hospital or ambulatory surgical center with dates of service on and after January 1, 2022, the out-of-network provider can sign the Surprise Bill Certification Form and send it to the health plan with the claim. 

Independent Dispute Resolution (IDR) for Surprise Bills.  Providers have a right to IDR to dispute a health plan payment for a surprise bill.  Learn how to submit a dispute through the IDR process.

Disclosure of Balance Billing Protections.  Providers must make publicly available (post in the provider’s public location), post on their public websites, and provide to patients, a one-page notice in clear and understandable language containing information on: 

• The Federal requirements and prohibitions relating to prohibitions on balance billing for emergency services and surprise bills;
• New York requirements prohibiting balancing billing for emergency services and surprise bills; and
• Information on contacting New York and Federal agencies in case an individual believes that a provider has violated any state or federal prohibitions on balance billing for emergency services and surprise bills. 

Model Disclosure Form.  NYS Department of Financial Services has a model disclosure form that providers can use. 

When Scheduling Appointments. A healthcare professional, or a group practice of health care professionals, a diagnostic and treatment center or a health center defined under 42 USC §254b on behalf of health care professionals rendering services at the group practice, diagnostic and treatment center or health center, is required to disclose to patients or prospective patients the following information:

• Health Plan Participation. The health plans in which the health care professional, group practice, diagnostic and treatment center or health center is a participating provider. This is required to be given in writing or through a website prior to the provision of non-emergency services and verbally at the time an appointment is scheduled.
• Hospital Affiliations. The hospitals with which the health care professional is affiliated. This is required to be given in writing or through a website prior to the provision of non-emergency services and verbally at the time an appointment is scheduled.
• Cost of Services. That the amount or estimated amount that the health care professional will bill the patient for health care services is available upon request if the health care professional does not participate with a patient's or prospective patient's health plan. Health care professionals are required to provide this information to patients prior to the provision of non-emergency services. Upon receipt of a request from a patient or prospective patient, the healthcare professional is required to disclose to the patient or prospective patient in writing the amount or estimated amount that will be billed for health care services provided or anticipated to be provided absent unforeseen medical circumstances. With respect to a health center, this may be provided in the form of a schedule of fees provided under 42 USC §254b(k)(3)(G)(i).

Physicians Arranging Services in Office or Coordinating or Referring a Patient for Services. A physician that schedules a health care provider to perform anesthesiology, laboratory, pathology, radiology or assistant surgeon services in connection with care to be provided in his or her office, or a physician that coordinates or refers a patient for such services, is required to provide a patient or prospective patient with the following at the time of referral to or coordination with such provider:

• The provider's name, if the physician schedules a specific provider in a practice.
• The provider's practice.
• The provider's address.
• The provider's telephone number.

Physicians Arranging for Inpatient or Outpatient Services in a Hospital. A physician that arranges for any other physicians to treat a patient during the patient's scheduled hospital admission or scheduled outpatient hospital services is required to provide the patient and the hospital, at the time non-emergency services are scheduled, with the following information regarding the other physicians whose services are scheduled at the time of the pre-admission testing, registration or admission:

• The physician's name, if the physician schedules a specific physician in the practice.
• The physician's practice.
• The physician's address.
• The physician's telephone number.
• How to determine the health plans in which the physician participates.

Hospital Website. A hospital is required to post on its website:

• Charges. A list of its standard charges for items and services provided by the hospital (or how to obtain this information if the list of charges is not posted).
• Health Plan Participation. The health plans in which it is a participating provider.
• A Statement Providing the Following Information About Charges of Physicians in the Hospital:
  • That physician services provided in the hospital are not included in the hospital's charges.
  • That physicians who provide services in the hospital may or may not participate with the same health plans as the hospital.
  • That the prospective patient should check with the physician arranging for the hospital services to determine the health plans in which the physician participates.
• Physician Groups With Which the Hospital Has Contracted. The name, address, and telephone number of the physician groups that the hospital has contracted with to provide services such as anesthesiology, pathology or radiology, and instructions how to contact these groups to determine the health plan participation of the physicians in the groups.
• Physicians Employed By The Hospital. The name, address, and telephone number of physicians employed by the hospital and whose services may be provided at the hospital, and the health plans in which they participate.
• Registration or Admission Materials. A hospital is required, in registration or admission materials provided prior to non-emergency hospital services, to:

Advise a Patient or Prospective Patient to Contact the Physician Arranging the Hospital Services to Determine:

• The name, practice name, address, and telephone number of any other physician whose services will be arranged by the physician.
• Whether the services of physicians who are employed or contracted by the hospital to provide services such as anesthesiology, pathology and radiology are reasonably anticipated to be provided to the patient.

Provide Patients With Instructions on How to Determine Physicians" Health Plan Participation. Provide patients or prospective patients with information as to how to timely determine the health plans participated in by physicians who are reasonably anticipated to provide services to the patient at the hospital and who are employees of the hospital or contracted by the hospital to provide services including anesthesiology, pathology and radiology.

Patient Hold Harmless and Claim Payment. Providers must hold patients harmless for any amount that is more than the patient's in-network cost-sharing (copayment, coinsurance, and deductible) for emergency services in hospital facilities. Health plans must pay providers a reasonable amount for the service rendered or attempt to negotiate reimbursement with the provider. Providers may dispute the amount that the health plan pays through the independent dispute resolution process.

Independent Dispute Resolution (IDR) for Emergency Services. Providers have a right to IDR to dispute a health plan payment for emergency services, including payment for inpatient services following an emergency room visit.

Learn how to submit a dispute through the IDR process.