Protecting Yourself - Surprise Bills
What you need to know to protect yourself from surprise bills:
If you have coverage through a fully insured commercial, Article 47 ASO group, Medicaid, or Child Health Plus: New York State has established a new process to resolve disputes on surprise bills. Health plans, doctors, facilities, and patients have the right to request an independent review from New York State if they do not believe a bill or its payment was reasonable.
What is a surprise bill?
When you receive services from a non-participating doctor at a participating hospital or ambulatory surgical center, the bill you receive for those services will be a surprise bill if:
- A participating doctor was not available; or
- A non-participating doctor provided services without your knowledge; or
- Unexpected medical circumstances occurred at the time the health care services were provides.
It will not be a surprise bill if you chose to receive services from a non-participating doctor instead of from an available participating doctor.
When you are referred by your participating doctor to a non-participating doctor, the bill you receive for those services will be a surprise bill if you did not sign a written consent form stating that you knew the services would be out-of-network and would result in costs not covered by your health plan.
A referral to a non-participating provider occurs when:
- During a visit with your participating doctor, a non-participating doctor treats you; or
- Your participating doctor takes a specimen from you in the office (for example, blood) and sends it to a non-participating laboratory or pathologist; or
- A referral is required under your plan for any other health care services.
Protect yourself from a surprise bill.
You can protect yourself from receiving a surprise bill and only be responsible for your in-network copay, coinsurance, or deductible if you:
- Call the customer service number on the back of your member ID card and ask for an Assignment of Benefits (AOB) form to fill out; and
- Send the form and a copy of the bill(s) you do not think you should pay to both your doctor and us.
If you don’t complete an AOB, you can also submit your disputed bill directly to New York State’s Independent Dispute Resolution Entity (IDRE) for review. For more information on submitting a dispute for review, visit the New York State Department of Financial Services website at dfs.ny.gov, call 1-800-342-3736, or e-mail IDRquestions@dfs.ny.gov.
How do we reimburse health care providers?
We use several nationally accepted methods to pay doctors, hospitals, and urgent care centers both in- and out-of-network.
Agreed-upon amount: This is a negotiated rate between BlueShield of Northeastern New York and a doctor, hospital, or urgent care center.
BlueCard program: This program was developed by the BlueCross BlueShield Association, a national organization of independent BlueCross and/or BlueShield plans, to make paying claims easy when you visit a doctor, hospital, or urgent care center outside of your coverage area. You pay your normal copay, deductible, or coinsurance, and the local Blue plan pays the rest.
Resource-based relative value scale: This scale was created by the federal government to help insurers determine pricing for medical procedures. This scale uses information such as the length of the procedure, general costs of running a practice, and geographic location to determine how much each medical procedure should cost.
Out-of-network reimbursement compared to Usual, Customary and Reasonable (UCR) cost: Our general out-of-network reimbursement to doctors for services received using out-of-network benefits is approximately 71 percent of UCR.UCR is the amount providers typically charge for a service.
Need help figuring out your treatment costs?
Fair Health® is a free website that can help you estimate the cost of health care services in your area. You can get estimates for both medical and dental procedures and coverage costs when you visit out-of-network doctors, hospitals, or urgent care centers.
Claim and Assignment of Benefits Form Submission
You can securely submit a claim to us by logging in to your account.
To submit an Assignment of Benefits Form, fill out the below form and email it to firstname.lastname@example.org or mail to NENY use PO Box 15013 Albany, NY 12212.