§ 3224-a. Standards for prompt, fair and equitable settlement of\nclaims for health care and payments for health care services. In the\nprocessing of all health care claims submitted under contracts or\nagreements issued or entered into pursuant to this article and articles\nforty-two, forty-three and forty-seven of this chapter and article\nforty-four of the public health law and all bills for health care\nservices rendered by health care providers pursuant to such contracts or\nagreements, any insurer or organization or corporation licensed or\ncertified pursuant to article forty-three or forty-seven of this chapter\nor article forty-four of the public health law shall adhere to the\nfollowing standards:\n (a) Except in a case where the obligation of an insurer or an\norganization or corporation licensed or certified pursuant to article\nforty-three or forty-seven of this chapter or article forty-four of the\npublic health law to pay a claim submitted by a policyholder or person\ncovered under such policy ("covered person") or make a payment to a\nhealth care provider is not reasonably clear, or when there is a\nreasonable basis supported by specific information available for review\nby the superintendent that such claim or bill for health care services\nrendered was submitted fraudulently, such insurer or organization or\ncorporation shall pay the claim to a policyholder or covered person or\nmake a payment to a health care provider within thirty days of receipt\nof a claim or bill for services rendered that is transmitted via the\ninternet or electronic mail, or forty-five days of receipt of a claim or\nbill for services rendered that is submitted by other means, such as\npaper or facsimile.\n (b) In a case where the obligation of an insurer or an organization or\ncorporation licensed or certified pursuant to article forty-three or\nforty-seven of this chapter or article forty-four of the public health\nlaw to pay a claim or make a payment for health care services rendered\nis not reasonably clear due to a good faith dispute regarding the\neligibility of a person for coverage, the liability of another insurer\nor corporation or organization for all or part of the claim, the amount\nof the claim, the benefits covered under a contract or agreement, or the\nmanner in which services were accessed or provided, an insurer or\norganization or corporation shall pay any undisputed portion of the\nclaim in accordance with this subsection and notify the policyholder,\ncovered person or health care provider in writing, and through the\ninternet or other electronic means for claims submitted in that manner,\nwithin thirty calendar days of the receipt of the claim:\n (1) whether the claim or bill has been denied or partially approved;\n (2) which claim or medical payment that it is not obligated to pay\nstating the specific reasons why it is not liable; and\n (3) to request all additional information needed to determine\nliability to pay the claim or make the health care payment; and\n (4) of the specific type of plan or product the policyholder or\ncovered person is enrolled in; provided that nothing in this section\nshall authorize discrimination based on the source of payment.\n Upon receipt of the information requested in paragraph three of this\nsubsection or an appeal of a claim or bill for health care services\ndenied pursuant to this subsection, an insurer or organization or\ncorporation licensed or certified pursuant to article forty-three or\nforty-seven of this chapter or article forty-four of the public health\nlaw shall comply with subsection (a) of this section; provided, that if\nthe insurer or organization or corporation licensed or certified\npursuant to article forty-three or forty-seven of this chapter or\narticle forty-four of the public health law determines that payment or\nadditional payment is due on the claim, such payment shall be made to\nthe policyholder or covered person or health care provider within‹ Prev All New York sections Next ›
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