FAQs

Out-of-Network Emergency Services

How are “emergency services” defined?

Emergency services generally refer to the following services provided to treat an emergency condition:

1. Medical screening exams that a hospital’s emergency department can perform, including ancillary services routinely used to assess emergency medical conditions, and
2. Additional medical exams and treatment required to stabilize a patient.

An emergency condition means a medical or behavioral condition that produces symptoms serious enough to qualify it as an emergency condition. An example is if you have severe pain that you know could result in one or more of the following without getting immediate medical attention:

• Extreme danger to the health of the person experiencing the emergency condition, or a behavioral condition
• Serious impairment to the bodily functions of the affected person
• Serious dysfunction of any bodily organ or part of the affected person
• Serious disfigurement of the affected person

Do the emergency services protections apply to my Carelon Behavioral Health plan?

The emergency services protections described apply to insured plan members whose health plan is administered by Carelon Behavioral Health and whose plan includes a provider network feature. Some or all of these protections may not apply to you if you are covered under any of the following types of plans or circumstances:

• Self-insured group health plan (other than the New York State Empire Plan);
• Medicare supplement plan;
• Medicare Advantage plan;
• Medicaid Managed Care or Medicaid Fee for Service;
• Medicare is your primary coverage (e.g. group health plan retiree benefits that supplement Medicare payments); or
• Other plans and circumstances as may be determined by New York law and regulations and/or the New York State Department of Financial Services.

Do the emergency services protections apply to emergency services I receive at an out-of-network urgent care center?

No. To be eligible for these protections, emergency services must be received in a hospital.

An ambulance took me to an in-network hospital. Without knowing it, I received emergency services from an out-of-network provider at that hospital. Am I responsible for the costs?

Since this was an emergency, you’re only responsible for paying your in-network cost-sharing (in-network copay, coinsurance and/or deductible) for the ambulance ride, the hospital visit and for the care you received from the out-of-network provider.

How does Carelon Behavioral Health process claims for out-of-network emergency services?

If Carelon Behavioral Health receives a claim for emergency services from an out-of-network provider, we’ll pay the claim at the amount we determine to be reasonable for the emergency services — except for any in-network cost-sharing (in-network copay, coinsurance and/or deductible) that applies under your plan.

If we pay an amount less than what the out-of-network provider charges, Carelon Behavioral Health will send you a notice — either within, or together with, your Explanation of Benefits — explaining that:

• Your out-of-pocket costs for the emergency services won’t be any higher than if you’d received them from an in-network provider,
• Your cost-sharing for the emergency services may increase if an IDRE (independent dispute resolution entity) decides Carelon Behavioral Health must pay an additional amount(s) for the physician services, and
• You should contact Carelon Behavioral Health if the out-of-network provider bills you for the out-of-network emergency services except for your in-network cost-sharing amount. For instructions, see the section “What to Do If You Get a Bill for Out-of-Network Emergency Services or Surprise Bills.”

We will also inform the out-of-network physician how to initiate the independent dispute resolution process in the event the physician is unsatisfied with our payment.

Non-Emergency Surprise Bills

What’s a “surprise bill”?

A surprise bill is a bill for covered non-emergency health care services, where one of the following situations applies:

1. You receive covered health services from an out-of-network physician at an in-network hospital or ambulatory surgical center, where either:
   • An in-network physician is unavailable
   • An out-of-network physician delivers services without your knowledge
   • You need unexpected medical services while receiving other services

   If you received the health care services when a network physician was available and you elected to obtain services from the out-of-network physician anyway, it is not a surprise bill.

2. An in-network physician referred you to an out-of-network provider, and you received covered health services from the out-of-network provider without your written consent acknowledging that you:
   • Knew the referred provider was outside your plan’s provider network, and
   • Knew that getting services from that out-of-network provider could result in costs not covered by Carelon Behavioral Health

   A referral to an out-of-network provider occurs when:

   • Health care services are performed by an out-of-network provider in the network physician’s office or practice during the course of the same visit,
   • The network physician sends a specimen taken from the patient in the network physician’s office to an out-of-network laboratory or pathologist, or
   • For any other health care services performed by an out-of-network provider, when referrals are required under your health plan contract or certificate of coverage.
3. A self-insured or uninsured individual receives health services from a provider at a hospital or ambulatory surgical center, where the provider did not share required information with a patient in a certain time frame.

Do the surprise bills protections apply to my Carelon Behavioral Health plan?

The surprise bills protections described apply to insured plan members whose health plan is administered by Carelon Behavioral Health and whose plan includes a provider network feature. Some or all of these protections may not apply to you if you are covered under any of the following types of plans or circumstances:

• Self-insured group health plan (other than the New York State Empire Plan);
• Medicare supplement plan;
• Medicare Advantage plan;
• Medicaid Fee For Service;
• Medicare is your primary coverage (e.g. group health plan retiree benefits that supplement Medicare payments); or
• Other plans and circumstances as may be determined by New York law and regulations and/or the New York State Department of Financial Services.

How do I know if a bill is a surprise bill?

Refer to the sections “Non-Emergency Surprise Bills” and “What to Do If You Get a Bill for Out-of-Network Emergency Services or a Surprise Bill.” If you still have questions, please contact the phone number for behavioral health (mental health/substance use) on your ID card.

Do these protections apply to services I choose to receive from an out-of-network provider?

Generally, no. If you knowingly opt to receive non-emergency services from an out-of-network provider rather than from in-network providers, the protections do not apply and you will be responsible for paying for the services of the out-of-network provider.

If your plan includes out-of-network benefits (usually called a PPO or POS plan), you generally will have benefits for most covered services even if you receive them out-of-network, but the cost-sharing and out-of-pocket expenses will generally be higher than if you had obtained services in-network. Be sure to check whether your plan has out-of-network benefits, and please review your contract or certificate of coverage for the terms and conditions of your out-of-network coverage.

I chose to see a provider who it turns out is not in my plan’s provider network. Do the protections apply?

Generally, no. In most cases, you are responsible for all bills for covered services you choose to receive from providers who are not in your plan’s provider network (usually called an HMO or EPO plan). So, before seeing a provider, be sure to confirm the provider participates in your plan’s provider network by checking the online provider directory, asking the provider’s office when making an appointment, or calling Carelon Behavioral Health to ask.

If your plan covers out-of-network services (usually called a PPO or POS plan), the out-of-network services may be eligible for coverage, according to the terms of your plan’s coverage for out-of-network services, though usually at higher cost-sharing and with more out-of-pocket costs than in-network services.

During my non-emergency surgery at an in-network hospital or surgical center, an out-of-network physician stepped in to perform services without my knowing it. Am I responsible for the costs?

Since you didn’t know you were getting out-of-network care, the protections apply and you are not responsible for any costs other than any applicable in-network cost-sharing (in-network copay, coinsurance and/or deductible) you owe under your plan.

My in-network primary care physician referred me to an out-of-network provider, and I saw that provider without knowing of her out-of-network status. Am I responsible for the costs?

It depends. If the referral occurred under a contract that requires referrals from PCPs or the referral was to another provider in your physician’s office or practice and you see the other provider during the course of the same visit with your physician where the referral occurred, then you are not responsible for any costs other than the applicable in-network cost-sharing you owe under your plan. If your physician referred you to an out-of-network provider outside of these situations, then you are responsible for the costs.

I had blood drawn in an in-network physician’s office, but the sample was sent to an out-of-network lab for testing. Am I responsible for the costs?

Since you did not consent in writing to have the blood sample sent to an out-of-network lab, you are not responsible for any costs beyond any applicable in-network cost-sharing you owe under your plan for the service.

Handling Surprise Bills

What should I do if I get a surprise bill from a provider’s office?

If a provider sends you a bill for a surprise bill, he or she must also provide you with an Assignment of Benefits Form. Complete and send this form, along with a copy of the bill, to Carelon Behavioral Health by mail or email for processing.

Mail	PO Box 1851 Hicksville, NY 11802
Fax	(855) 378-8309
Email	nysurprisebill@carelonbehavioralhealth.com

For instructions on submitting these documents, see the section “What to Do If You Get a Bill for Out-of-Network Emergency Services or a Surprise Bill.” You also must submit a copy of the Assignment of Benefits Form to your provider.

Carelon Behavioral Health has already processed a claim for what I believe is a surprise bill, but I am being asked to pay more than my in-network cost-sharing. What should I do?

You should complete and submit to Carelon Behavioral Health a standard surprise bill Assignment of Benefits Form, or contact the phone number for behavioral health (mental health/substance use) on your ID card. Customer Service will ask you to complete and submit the standard surprise bill Assignment of Benefits Form when you call.

If you feel a payment decision is incorrect, you also can file a grievance with Carelon Behavioral Health by calling Customer Service or submitting a dispute by mail, fax or email.

For instructions on submitting forms and filing grievances, see the section “Disputing Claims for Out-of-Network Emergency Services or Surprise Bills.”

Estimating Out-of-Network Care Costs

What is cost-sharing?

Cost-sharing describes the portion of our plan allowances that you are responsible for paying. There are a few types of cost-sharing (i.e., copay, coinsurance and/or deductible) that plan members may need to pay to use covered health services. Cost-sharing does not include premiums, which is the cost of your health care plan either each month or over a given time period. If your plan includes out-of-network coverage, cost-sharing also does not include the difference between the Carelon Behavioral Health’s allowance (the maximum amount we pay for a service) and the charges of an out-of-network provider, which you are also responsible for paying.

If I receive out-of-network emergency services or services that would qualify as a “surprise bill,” will my cost-sharing and out-of-pocket costs be higher than if I had received in-network care?

No. In these cases, your cost-sharing will be at the in-network cost-sharing amount(s), as defined under your plan.

Is there any way to estimate what I would pay out of pocket for out-of-network services?

Yes. To identify Carelon Behavioral Health’s allowance for a specific service, please contact us at the phone number for behavioral health (mental health/substance use) on your ID card.

Carelon Behavioral Health Provider Networks

How do I know if a provider participates in my plan’s provider network?

To find a provider that participates in your plan use our provider search tool on MemberConnect. If you are a registered user please login or you may enter as a guest and follow the prompts.

If a provider says they participate with Carelon Behavioral Health, are they sure to be in my plan’s provider network?

No. Providers may participate in some Carelon Behavioral Health’s networks, but not in others. So, when you make an appointment to see a provider, be sure to tell the provider’s office which type of coverage you have.

Will Carelon Behavioral Health be making changes to any of its provider networks to account for the new protections for out-of-network emergency services and surprise bills?

No. At this time, Carelon Behavioral Health will not be changing our provider networks based on these new protections.

More Information

Where can I get more information on the out-of-network payment protections?

Please visit the dedicated web page of New York State’s Department of Financial Services.

Questions?

Please contact Carelon Behavioral Health at the phone number for behavioral health (mental health/substance use) on your ID card. 8 a.m. to 8 p.m. ET, Monday – Friday (excluding major holidays). TTY/TDD users, please call 711.

¹Please note that the emergency services and surprise bills protections described do not apply to you if your plan does not include a provider network feature. Some or all of these protections may also not apply to you if you are covered under any of the following types of plans or circumstances:

• Self-insured group health plan (other than the New York State Empire Plan);
• Medicare supplement plan;
• Medicare Advantage plan;
• Medicaid Managed Care plan or Medicaid Fee for Service;
• Medicare is your primary coverage (e.g. group health plan retiree benefits that supplement Medicare payments); or
• Other plans and circumstances as may be determined by New York law and regulations and/or the New York State Department of Financial Services.