1. What is a surprise bill?
A surprise bill is when a member gets services from an out-of-network provider at an in-network hospital or other center and receives a bill for those services.
A member may get a surprise bill because:
If the member chooses to receive services from an out-of-network provider, charges for the services are not considered surprise bills.
If you are a member and receive a bill that you believe is a surprise bill, please fill out this Assignment of Benefits Form. Sign, scan, and email it to a email@example.com or send by regular mail to:
P.O. Box 5165
New York, NY 10274-5165
If we determine that you have received a surprise bill, you will not have to pay charges except for any applicable co-pays, coinsurance, or deductibles. This is sometimes called a “hold harmless” rule.
2. What if Healthfirst pays an out-of-network provider less than what was charged for emergency services?
If a member gets emergency services from an out-of-network provider and Healthfirst paid that provider less than what was charged, the member will not have any costs greater than any applicable co-pays, coinsurance, or deductibles.
In some cases, these costs the member owes may increase. This may happen if an Independent Dispute Resolution Entity (IDRE) decides that Healthfirst must pay the out-of-network provider an amount higher than what Healthfirst originally paid.
If you are a member and get a bill from an out-of-network provider for emergency services, please contact us at 1-888-250-2220.
3. As a provider, can I dispute the costs that Healthfirst has not covered?
If you are a provider and not satisfied with the amount Healthfirst has covered for a surprise bill or out-of-network emergency service, you can submit a complaint to an Independent Dispute Resolution Entity (IDRE).
4. As a provider, how do I submit a claim to an IDRE?
To submit a claim to an Independent Dispute Resolution Entity (IDRE), a healthcare provider must:
5. I have additional questions about surprise bills and Independent Dispute Resolution.
If you have additional questions, please call 1-800-342-3736, or e-mail your questions to IDRquestions@dfs.ny.gov.