If Carelon Behavioral Health reimburses an out-of-network provider for an emergency service or surprise bill with an amount he or she determines to be unreasonable, or if Carelon Behavioral Health and the provider cannot otherwise agree on an appropriate payment for the service, the provider or Carelon Behavioral Health may submit the dispute to an independent dispute resolution (IDR) process through the New York State Department of Financial Services.
Members covered under self-insured plans and individuals who do not have insurance may also access the IDR process in some circumstances.
The following describes how out-of-network providers should proceed to submit a dispute through the IDR process for emergency services or surprise bills:
- Health care providers for disputes with a health plan involving an insured patient. To submit a dispute, health care providers must:
- Visit the New York State Department of Financial Services (DFS) website to receive a file number,
- Complete the IDR application available on the DFS website, and
- Send the application to the assigned independent dispute resolution entity.
- Uninsured patients or patients with employer or union self-insured coverage, or insured patients who do not assign benefits for surprise bills. To submit a dispute, patients must complete this application and send it to NYS Department of Financial Services, Consumer Assistance Unit/IDR Process, One Commerce Plaza, Albany, NY 12257.
For assistance, call 1-800-342-3736 or e-mail IDRquestions@dfs.ny.gov.
A physician or health care provider shall provide the following information:
- The name and contact information of the physician or non-participating referred health care provider;
- The name and contact information of the health care plan;
- The fee charged by the physician or non-participating referred health care provider for the service that is the subject of the dispute, and provide a copy of the bill;
- The fee paid to the physician or non-participating referred health care provider for the service that is the subject of the dispute;
- At least three fees paid to the physician or, if the dispute involves a health care provider to the non-participating referred health care provider, in the last 12 months for the same services rendered by the physician or non-participating referred health care provider to other patients in health care plans in which the physician or non-participating referred health care provider is not participating, if available;
- The physician’s or non-participating referred health care provider’s usual charge for comparable services rendered to other patients in health care plans in which the physician or non-participating referred health care provider is not participating;
- The physician’s or non-participating referred health care provider’s level of training, education and experience;
- An explanation of the circumstances and complexity of the particular case, including time and place of the service;
- Individual patient characteristics;
- The usual and customary cost for the service, if available and applicable;
- Any other information the physician or non-participating referred health care provider deems relevant;
- An attestation affirming that the information provided by the physician or non-participating referred health care provider is true and accurate; and
- Any information requested by the IDR entity.