N.Y. Comp. Codes R. & Regs. tit. 23 § 400.8

Current through Register Vol. 46, No. 45, November 2, 2024

Section 400.8 - Responsibilities of an IDRE

(a) Within three business days of receipt of an application submitted by a health care plan, non-participating physician, non-participating hospital, non-participating referred health care provider or a patient, an IDRE shall screen the application for any conflicts of interest in accordance with section 400.4 of this Part. If the IDRE determines a conflict exists, the IDRE shall reject the application and return it to the superintendent within those three business days.

(b) If the IDRE determines that a conflict does not exist, the IDRE shall, within three business days of receiving an application submitted by a health care plan, non-participating physician, non-participating hospital, or non-participating referred health care provider:

(1) screen the application for eligibility;

(2) contact the health care plan, physician, hospital, or non-participating referred health care provider if additional information is needed to determine eligibility of the request for dispute resolution and provide the health care plan, the physician, hospital, or non-participating referred health care provider three business days to submit the information and provide an explanation of where the information should be sent. If the information is not submitted, the IDRE shall make a second request and provide one business day to submit the information. If the information is not submitted, or if the application is not eligible, the IDRE shall promptly reject the application.

(c) Within three business days of a determination that the health care plan's, physician's, hospital's or nonparticipating referred health care provider's application is eligible, or within three business days of receipt of the patient's application from the superintendent, the IDRE shall send notification of the assignment to the health care plan, physician, hospital, non-participating referred health care provider and, for a patient initiated application, to the patient. The IDRE shall include in the notification:

(1) a request for the information specified in subdivisions (c), (d), and (e) of section 400.7 of this Part;

(2) a request for any additional information that may be available to support the appeal;

(3) an explanation of where the information should be sent;

(4) a statement that all information must be submitted within five business days of the notification;

(5) a statement that if a partial response or no response is received, the dispute will be decided based on the available information; and

(6) a statement that the IDRE shall not reconsider a dispute for which a determination has been made based upon receipt of additional information subsequent to such determination.

(d) If the requested information is not received within five business days, the IDRE shall make a determination based on the information available to the IDRE. If the requested information or additional information is received before the determination is rendered, the IDRE shall consider the information.

(e) If the IDRE determines, in a case involving a health care plan, based on the health care plan's payment or best and final offer, if applicable, and the non-participating physician's or non-participating referred health care provider's fee, or the non-participating hospital's fee or best and final offer, as applicable, that a settlement between the health care plan and the non-participating physician, non-participating hospital, or non-participating referred health care provider is reasonably likely, or that both the health care plan's payment or best and final offer, if applicable, and the non-participating physician's or non-participating referred health care provider's fee, or the non-participating hospital's fee or best and final offer, as applicable, represent unreasonable extremes, the IDRE may direct both parties to attempt a good faith negotiation for settlement. The health care plan and the non-participating physician, non-participating hospital, or non-participating referred health care provider may be granted up to ten business days for this negotiation, which shall run concurrently with the 30 day period for dispute resolution.

(f) The IDRE shall have the dispute reviewed by a neutral and impartial reviewer with training and experience in health care billing, reimbursement, and usual and customary charges. All determinations shall be made in consultation with a neutral and impartial licensed reviewing physician in active practice in the same or similar specialty as the physician providing the service that is subject to the dispute. To the extent practicable, the reviewing physician shall be licensed in this State.

(g) An IDRE shall make a determination within 30 days of receiving the request for the dispute resolution.

(h) For disputes involving a health care plan, in determining a reasonable fee for the services rendered, an IDRE shall select either the health care plan's payment, or in cases involving a non-participating hospital that had previously entered into a participating provider agreement with the health care plan, the health care plan's best and final offer, if applicable, or the non-participating physician's or non-participating referred health care provider's fee, or the non-participating hospital's fee, or, in cases involving a non-participating hospital that had previously entered into a participating provider agreement with the health care plan, the nonparticipating hospital's best and final offer, as applicable . For disputes that do not involve a health care plan, the IDRE shall determine a reasonable fee.

(i) An IDRE shall use the conditions and factors set forth in Financial Services Law section 604 when determining the reasonable fee and shall consider any other information submitted by the parties pursuant to subdivisions (c)(10), (d)(11), and (e)(7) of section 400.7 of this Part.

(j) An IDRE shall forward copies of the dispute resolution determination to the health care plan, physician, hospital, or non-participating referred health care provider, superintendent, and as applicable, patient, within two business days of rendering the determination. The notification shall include:

(1) the fee determined to be reasonable along with the reasons for the determination, including a discussion of the fee charged by the physician, hospital, or non-participating referred health care provider, or, as applicable, the non-participating hospital's best and final offer; the fee paid by the health care plan, or, in cases involving a non-participating hospital, the health care plan's best and final offer, if applicable; the usual and customary charge for disputes involving physician services; and other information provided;

(2) a statement attesting that no prohibited material affiliation existed with respect to the reviewer or reviewing physician;

(3) the biographies of the reviewer and the reviewing physician; and

(4) a request for payment to the party that does not prevail.

(k) An IDRE shall not divulge to the health care plan, physician, hospital, non-participating referred health care provider or patient the name of the reviewer or reviewing physician assigned to the dispute.

(l) For each dispute resolution determination made by the IDRE, the IDRE shall certify that:

(1) the IDRE, the reviewer and the reviewing physician assigned to review the dispute followed appropriate procedures as specified in Financial Services Law article 6 and this Part;

(2) the reviewer and reviewing physician met the criteria for conducting the dispute pursuant to Financial Services Law article 6 and this Part; and

(3) for the reviewer and reviewing physician assigned to review the dispute, the IDRE has obtained a signed attestation affirming, under penalty of perjury, that no prohibited material affiliation exists with respect to the reviewer's or reviewing physician's participation in the review of the dispute pursuant to section 400.4(d) of this Part. The attestation shall be in such form as prescribed by the superintendent.

(m) An IDRE shall not reconsider a dispute for which a determination has been made based upon receipt of additional information subsequent to the determination.

N.Y. Comp. Codes R. & Regs. Tit. 23 § 400.8

Adopted New York State Register June 3, 2015/Volume XXXVII, Issue 22, eff. 6/3/2015

Amended New York State Register July 14, 2021/Volume XLIII, Issue 28, eff. 8/13/2021