Find policies, billing codes, payers, states, and providers
New York State Surprise Medical Bill Certification Form and IDR guidance
Customize your policy alerts
Sign up for all Aetna policy alerts
Know when Aetna releases new policies or updates existing guidance.
Monitor payer policy activity
Explains New York protections against surprise medical bills and the Certification Form process, who is eligible for Independent Dispute Resolution (IDR), and instructions for patients, providers, and plans in New York. Affects members, providers, and plans subject to New York regulations, including self-funded plan participants and uninsured patients.
No material clinical or coverage changes in this revision.
New York Surprise Billing Protections & IDR Eligibility
NY surprise billing protections and IDR eligibility
Services and circumstances covered by New York surprise billing protections and eligibility for Independent Dispute Resolution (IDR):
Eligible service categories
- Out-of-network emergency services provided by a physician (member responsible only for in-network cost share).
- Out-of-network emergency services provided by a hospital (member responsible only for in-network cost share).
- Out-of-network inpatient services provided by a hospital or physician following an emergency room visit at an out-of-network hospital.
- Services by out-of-network providers at in-network hospitals and ambulatory care centers (may be surprise bills when criteria below are met).
Circumstances that constitute a surprise bill
- Member receives covered non-emergency services at a participating facility or ambulatory surgical center and the bill is from an out-of-network provider because a participating provider was not available, unforeseen services arose at the time of care, or the member was not informed the provider was out-of-network.
- A participating physician refers a member to a non-participating provider and the member was not made aware and did not sign written consent acknowledging out-of-network status and potential additional costs.
- At a participating physician's office: a nonparticipating provider treats the member without the member's express written consent; a participating physician takes a specimen and sends it to a nonparticipating lab or pathologist; or a participating physician refers the member for out-of-network care when referrals are required.
- Patient covered under a self-funded or uninsured plan receives care at/from a hospital, ambulatory surgical facility or physician and the provider failed to give required disclosures under Section 24 of the New York Public Health Law.
Eligibility and scope notes
- Protections apply to emergency services performed in New York; for all emergency services (regardless of location), members are responsible only for their in-network cost share; members may assign benefits using the New York Assignment of Benefits form or use the Certification form.
- Self-funded plan members and uninsured patients may file IDR for emergency services and surprise bills; IDR decisions are binding on patient and provider as applicable.
Exclusions / not a surprise bill
- Not a surprise bill when a network provider was available and the member knowingly elected to receive care from an out-of-network provider (i.e., member signed informed written consent).
Process to initiate IDR and provider administrative actions
- To initiate IDR, complete and submit the NY DFS IDR application via the New York Department of Financial Services portal; DFS will assign an IDR entity to resolve fee disputes.
- Providers should give patients the Surprise Bill Certification form when billing over the in-network cost share and must send copies to the member and the member's health plan as instructed; providers may complete and submit the Certification form when billing the plan or seeking assignment of benefits.
Eligible Service Categories and Form Timing
| Out-of-network emergency services provided by a physician | |
| Out-of-network emergency services provided by a hospital | |
| Out-of-network inpatient services provided by a hospital or physician following an emergency room visit at an out-of-network hospital | |
| Services by out-of-network providers at in-network hospitals and ambulatory care centers |
Filing IDR and Submitting the Surprise Bill Certification
Initiate IDR via NY DFS
If insurer and provider disagree on fees for eligible New York surprise or emergency claims, either party may file an Independent Dispute Resolution (IDR) application via the New York Department of Financial Services (DFS) portal. Complete the IDR application on the DFS website and submit it through the DFS IDR portal at DFS.NY.gov; DFS will assign an IDR entity to resolve the fee dispute. IDR eligibility requires that the dispute meet the New York surprise bill definition or be for emergency services performed in New York.
- Either the insurer or the provider can file IDR for eligible claims.
- Steps: (1) complete an IDR application on the DFS website; (2) send it via the DFS IDR portal (DFS.NY.gov).
- DFS will assign an IDR entity (IDRE) to resolve the fee dispute.
- Eligible disputes must meet the New York surprise bill definition or be for emergency services in New York.
Submit Surprise Bill Certification to health plan
When billing a member for more than the in‑network cost‑sharing for a potential surprise bill, providers may complete the New York Surprise Medical Bill Certification form and must send a copy to the member's health plan. For certain surprise bills before 1/1/22 and for specified categories for all dates of service the form is required; for surprise bills in (1) on or after 1/1/22 the form is not required but providers may still complete and must send it to the health plan when they complete it on the patient’s behalf.
- Send a copy of the completed form to the provider and the member’s health plan (include a copy of any bill received).
- The form is required for some surprise bills before 1/1/22 and for specified categories for all dates; for (1) after 1/1/22 it is not required but may be used to identify surprise bills.
- If the provider completes the form for dates of service on or after 1/1/22, the provider must send it to the health plan.
Key Terms
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.