CurrentAetnaPolicy N/A

New York State Surprise Medical Bill Certification Form and IDR guidance

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.

Policy Summary

PayerAetna

PolicyNew York State Surprise Medical Bill Certification Form and IDR guidance

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionIf disputing fees for eligible New York surprise or emergency claims, file an IDR application via the New York Department of Financial Services portal.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

IDRmechanism to resolve out-of-network fee disputes

Form includedSurprise Bill Certification form provided

Emergency & surpriseclaims eligible

Assign benefitspatient option

New York Surprise Billing Protections & IDR Eligibility

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NY surprise billing protections and IDR eligibility

Services and circumstances covered by New York surprise billing protections and eligibility for Independent Dispute Resolution (IDR):

Covered emergency and surprise-billing situations eligible for NY protections and IDR include the following categories:

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

Eligible service categories (informational)mixed

	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

Form requirement timing

When requiredForm required for surprise bills described in category (1) for dates of service before 1/1/22; required for surprise bills described in category (2) for all dates of service.

Use on/after 1/1/22Form is NOT required for category (1) surprise bills for dates of service on and after 1/1/22 but may be used to help identify surprise bills; providers may complete the form for category (1) bills on and after 1/1/22 and must send it to the member's health plan.

DistributionA copy of the completed form must be sent to the provider and the member's health plan (include any bill received).

Filing IDR and Submitting the Surprise Bill Certification

Prior Authorization

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.

Documentation Required

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

Surprise bill — definition & features

DefinitionA surprise bill occurs when a member receives covered non-emergency services at an in‑network facility but is treated by an out‑of‑network provider without prior notice or written consent, or when a participating physician refers to a non‑participating provider without the member's informed written consent.

Common scenariosIncludes out‑of‑network providers at in‑network hospitals/ambulatory surgical centers, unexpected services during care, and out‑of‑network care in a participating physician's office without express written consent.

Exclusions/notesNot a surprise bill when a member knowingly elects an out‑of‑network provider instead of an available in‑network provider or signs written consent acknowledging out‑of‑network care and potential costs.

IDR (Independent Dispute Resolution)

DefinitionIndependent Dispute Resolution (IDR) is the New York process for resolving fee disputes between insurers and providers for eligible out‑of‑network and emergency services, administered via the New York Department of Financial Services (DFS).

How to initiateEither party files an IDR application on the NY DFS website and submits it through the DFS IDR portal; DFS assigns an IDR entity to resolve the dispute.

Eligibility triggerIDR applies when the out‑of‑network claim dispute meets the New York surprise bill definition or is for emergency services performed in New York.

Surprise Bill Certification Form — definition & purpose

PurposeThe Surprise Bill Certification Form is used by a patient or provider to certify that services meet the surprise bill definition and to authorize the provider to seek payment from the patient's health plan or record an assignment of benefits.

Who may completeThe patient may complete and sign the form to have the provider seek payment from the health plan (assignment); a provider may complete the form for services described for dates of service on and after 1/1/22.

Required handlingSend a copy of the completed form to the provider and the health plan and include a copy of any bill received; the form contains fraud warning and requires signature and date.