New York Independent Dispute Resolution (IDR) for emergency services and surprise bills
Customize your policy alerts
Sign up for all bannerhealthandaetnahealthinsurancecompany policy alerts
Know when bannerhealthandaetnahealthinsurancecompany releases new policies or updates existing guidance.
Monitor payer policy activity
Notice describing New York law protections against balance billing for emergency services and surprise nonparticipating provider services, eligibility for IDR, and procedural resources for members, providers, and self-funded/uninsured patients.
No material clinical or coverage changes in this revision.
Coverage protections and IDR eligibility
IDR and surprise-bill criteria and actions
Protections and IDR eligibility apply when an out-of-network claim meets New York's surprise-bill definition or is for emergency services performed in New York; self-funded plans and uninsured patients may also file IDR. When insurers and providers disagree on fees for eligible claims either party may initiate IDR via the New York Department of Financial Services (DFS) portal.
Claim must be for a member enrolled in a plan subject to New York regulations; either party may file for IDR when they disagree on fees via the DFS IDR portal (DFS.NY.gov).
ONE of
- Out-of-network claim meets New York surprise bill definition
Examples include out-of-network provider at an in-network facility without member knowledge; referral to non-participating provider without member awareness or written consent; specimen sent to non-participating lab; failure to provide required disclosures under NY Public Health Law section 24.
- Out-of-network emergency services performed in New York
Includes out-of-network emergency services by physicians or hospitals; out-of-network inpatient services following an ER visit at an out-of-network hospital; and services by out-of-network providers at in-network hospitals and ambulatory care centers.
IDRE decision is binding on the patient and the provider.
Members may also assign benefits using the New York Assignment of Benefits form or utilize the Surprise Bill Certification form provided with this notice.
Complete the IDR application on DFS.NY.gov and submit on the DFS IDR portal.
Certification and assignment forms are provided with this notice to assist filing and assignment of benefits.
Service categories, forms, and coding notes
| No codes listed |
What providers and insurers must do
Initiate IDR via the NY DFS portal
When an insurer and a provider disagree on an out-of-network fee for an eligible New York claim, either party may file an Independent Dispute Resolution (IDR) application through the New York Department of Financial Services. Complete the IDR application on the DFS website and submit it via the DFS IDR portal; DFS will assign an IDR entity to resolve the fee dispute.
Provide Surprise Bill Certification and Assignment of Benefits
Provide the member with a Surprise Bill Certification form when you intend to bill more than the member's in‑network cost share for a potential surprise claim. Members may also assign benefits using the New York Assignment of Benefits form; providers may complete and submit these forms to support billing and IDR processes.
- Give the Surprise Bill Certification form (provided as the last page of the notice) when billing over in‑network cost share.
- Offer the New York Assignment of Benefits form to allow members to assign benefits for emergency or surprise billing situations.
- Contracted providers should coordinate care with participating providers to avoid creating surprise bills.
Key definitions
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.