Out-of-Network Surprise Medical Bill

A “Surprise Bill” is when you have insurance coverage issued in the State of NY:

Hospital or surgical centers: You are a patient at a participating hospital or ambulatory surgical center and you receive services for which:

• A network doctor was not available
• An out-of-network doctor provided without your knowledge
• Unforeseen medical circumstances arose at the time the health care services were provided

It will not be a surprise bill if you chose to receive services from an out-of-network doctor instead of form an available network doctor.

Referrals: Your network doctor did not ask your consent to refer you to an out-of-network doctor, lab or other health care provider, and did not tell you it would result in costs not covered by your health plan.

An independent dispute resolution entity (IDRE) can determine if you need to pay the bill. You, the plan or your doctor may request an independent dispute resolution (IDR) for surprise bills and referrals. Use the form on the next page to submit your request. You do not have to pay the bill in order to be eligible to submit the dispute for review to an IDRE.