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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. Excludes air ambulance.

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 Highmark Blue Shield of Northeastern New York and a doctor, hospital, or urgent care center.

BlueCard program: This program was developed by the Blue Cross Blue Shield Association, a national organization of independent Blue Cross and/or Blue Shield 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?

Visit fairhealthconsumer.org

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 customerservice@bsneny.com or mail to NENY use PO Box 15013 Albany, NY 12212.

No Surprises Act

For consumers who get coverage through their employer (including a federal, state, or local government), through the Health Insurance Marketplace® or directly through an individual health plan, beginning January 2022, these rules will protect you from surprise billing or balance billing when you receive emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center.

What is "balance billing" (sometimes called "surprise billing")?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan's network.

"Out-of-network" describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called "balance billing." This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

 "Surprise billing" is an unexpected balance bill. This can happen when you can't control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan's in-network cost-sharing amount (such as copayments and coinsurance). You can't be balance billed for these emergency services. This includes services you may get after you're in stable condition, unless you give written consent and give up your protections
not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan's in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can't balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers can't balance bill you, unless you give written consent and give up your protections.

You're never required to give up your protections from balance billing. You also aren't required to get care out-of-network. You can choose a provider or facility in your plan's network

When balance billing isn't allowed, you also have the following protections:

 

  • You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
  • Your health plan generally must:
    • Cover emergency services without requiring you to get approval for services in advance (prior authorization).
    • Cover emergency services by out-of-network providers.
    • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
    • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact No Surprises Help Desk (NSHD) at 1-800-985-3059 Or visit https://www.cms.gov/nosurprises for more information on your protections under the act.
 

Note: The rules don’t apply to people with coverage through programs like Medicare, Medicare Advantage, Medigap, Children’s Health Insurance Program (CHIP), and standalone Dental or Vision Plans.

Customer Service

Telephone
(800) 888-1238 Toll free

(518) 220-4600 Local

Monday - Friday: 8 a.m. - 8 p.m.

Saturday & Sunday: Closed
 

Mailing Address

Highmark Blue Shield of Northeastern New York

P.O.Box 15013
Albany, NY 12212