Out-of-Network

Understanding the Out-of-Network Mandate

Effective March 31, 2015, New York State law requires doctors and hospitals to more clearly communicate with patients about their health plan affiliations. The Out-of-Network (OON) mandate, which was designed to create greater transparency within the health care system, will also protect patients from receiving so-called “surprise” medical bills. Click any of the links below for more information on how this law affects you

• Disclosure of OON Coverage and Cost Information
• Surprise Bills
• Appeal Rights

Disclosure of OON Coverage and Cost Information

There are several steps CDPHP^® is taking to comply with the OON Mandate and provide our members with the information they need to make informed decisions:

• We are continuing to ensure our provider directories are accurate and up-to-date, including listings of participating providers and the languages spoken by those providers.
• To help you understand how much we would pay for certain OON services, we’ve created some out-of-network reimbursement examples for small business coverage and out-of-network reimbursement examples for large business coverage.

You can also visit the Fair Health website to determine the usual and customary rate (UCR) for OON services. For more information about your rights as a health insurance consumer, visit the Department of Financial Services website.

Surprise Bills: What They Are and What to Do with Them

What is a surprise bill?

• When you receive services from an out-of-network doctor at an in-network hospital or ambulatory surgical center, the bill you receive for those physician services will be a surprise bill if:
  • An in-network doctor was not available; or
  • An out-of-network doctor provided services without your knowledge; or
  • Unforeseen medical circumstances arose at the time the health care services were provided.

• When you are referred by your in-network doctor to an out-of-network provider, the bill you receive for the services provided by the out-of-network provider will be a surprise bill if:
  • You did not sign a written consent form that you knew the services would be out-of-network and would result in costs not covered by CDPHP.

• A referral to an out-of-network provider occurs when:
  1. You receive health care services from an out-of-network doctor in an in-network doctor’s office or practice during the same visit;
  2. Your in-network doctor sends a specimen taken in their office to an out-of-network laboratory or pathologist;
  3. Referrals for any other health care services are required under your contract (i.e., a gatekeeper).

• For uninsured or self-funded CDPHN members, a surprise bill occurs when you receive services from a doctor at a hospital or ambulatory surgical center if you have not received all of the required information about your care before the services are provided.

What a surprise bill is NOT

If you electively seek care from an out-of-network doctor when an in-network doctor is available, any bills you receive are not considered to be surprise bills.

If you have a bill and you have questions on whether it meets this definition, please contact the Department of Financial Services at 1-800-342-3736.

Emergency Medical Services

The new law also requires CDPHP to hold members harmless for all emergency costs in excess of your in-network cost sharing and prevents out-of-network physicians from balance billing you for any extra charges.

What to do if you receive a surprise bill or a bill for emergency services from an out-of-network doctor

The new law gives patients who receive surprise bills or a bill for emergency services from an out-of-network doctor, the right to appeal through an independent dispute resolution entity (IDRE), which will make a determination within 30 days of receiving the request.

If you are insured through a commercial or state-funded CDPHP® plan, you can dispute a surprise bill by completing an Assignment of Benefits form. Send one copy of the form to the doctor who provided the services and one copy to CDPHP by emailing it to us using the secure member site, or by mailing it to us at:

CDPHP
500 Patroon Creek Blvd.
Albany, NY 12206

CDPHP will dispute the bill on your behalf and you will be responsible for only your in-network cost share for covered services.

If you have health coverage through an employer that self-insures or if you are uninsured, you may dispute a bill through the New York State Independent Dispute Resolution Process.  

Ask your employer if you’re unsure about which applies to you.

Appeal Rights

The OON Mandate has also resulted in updates to the CDPHP utilization review and grievance/appeal processes.

• CDPHP will provide greater detail in certain approval notices indicating where the requested services are considered in-network or out-of-network.  Additionally, the notices will estimate the dollar amount CDPHP will pay if the service is out-of-network.  Members will also be provided information on how to estimate their out-of-pocket costs for out-of-network services.
• A member who is denied referral to an OON provider on the basis that a network provider with adequate training and experience is available now has the option to appeal this denial through the state’s external appeal process.