Information for members of New York Insurance Plans: Emergency Services and Surprise Bills

What is a surprise bill?

A surprise bill is a bill you receive for covered services performed by a non-participating (out-of-network) health care provider in the following circumstances:

1. The out-of-network provider performs services at a participating (network) hospital or ambulatory surgery center and:

• A network doctor is not available at the time the health care service was performed; or
• An out-of-network provider performs services without your knowledge.

2. A network provider refers you to an out-of-network provider without your written consent. If your plan does not require referrals, a surprise bill only occurs in limited circumstances. For example, when during your office visit a network doctor brings in an out-of-network provider or sends bloodwork to an out-of-network laboratory without your written consent.
3. You receive out-of-network (OON) emergency hospital services, including inpatient services following an emergency room visit.

A surprise bill does not include a bill for health care services when you choose to see an out-of-network provider.

What is an out-of-network provider?

An out-of-network provider is a doctor, health care professional, or facility (like a hospital or ambulatory surgery center) who isn’t part of your plan network. You may pay more for services you get from out-of-network providers.

What happens when I use an out-of-network provider?

Your costs may be higher. A facility must inform you if any out-of-network providers will be involved in your care. If you are not informed, you will only be responsible to pay your in-network deductible, co-pay or co-insurance amount. A surprise bill does not include a bill for health care services when you agree to see an out-of-network provider.

If I go to a network hospital will all of the providers be in the network?

Maybe. Sometimes specialists like emergency room doctors, anesthesiologists, radiologists or pathologists are not part of your network. For example, if you go to a network hospital and get an X-ray, the doctor reading the X-ray may not be in the network.

How do I make sure I receive care from a network provider?

When receiving care, please make sure to ask that all services you receive are from network providers. You should also confirm that any new doctor or health care provider is in the network for your plan.

To find a network provider:

• Log into myuhc.com® and select Find a Provider; or
• Call us at the phone number on your health plan ID card, and we’ll be happy to help.

What if I have an emergency?

You should go to the nearest emergency room for treatment.

How much will I be responsible to pay for emergency and surprise bills?

For either a surprise bill or emergency services, you will only be responsible to pay your in-network deductible, co-pay or co-insurance amount. We may initially pay the claim at the out-of-network level until further information is provided.

What should I do if I get a surprise bill or a bill for emergency services?

If you receive a bill from an out-of-network provider and believe it is a surprise bill or a bill for emergency services, do not pay the provider. Call the phone number on your health plan ID card. We may request that you submit additional information needed to determine whether it is a surprise bill. If you receive a surprise bill, you will need to fill out and submit the New York State Out-of-Network Surprise Medical Bill Assignment of Benefits Form.  The form and instructions are available at https://dfs.ny.gov/search/site?search=assignment+of+benefits+form. 

We may attempt to negotiate with the provider or pay an additional amount to resolve the claim. If we pay more, your cost share may increase.

Where should I send the New York Assignment of Benefits form?

Please send the completed New York Assignment of Benefits form and a copy of the bill to UnitedHealthcare at the address listed on your health plan ID card, or submit electronically at https://nyrmo.optummessenger.com/public/opensubmit.

What if the provider disagrees with the amount paid?

If the provider disagrees, the provider may submit the dispute for review through New York’s independent dispute resolution process. After the dispute is resolved, your cost share may increase if the health plan is told they must pay additional amounts.

What is the independent dispute resolution process?

New York will select an independent dispute resolution entity (IDRE) to review claims for emergency services and surprise bills where the payment amount can’t be agreed upon. The IDRE will receive information about the services received and determine the reasonable fee for the services. The IDRE will issue a decision accepting either our payment amount or the provider’s billed charge. For surprise bills, a dispute may be submitted to the IDRE for review by a health care plan, an out-of-network physician, an out-of-network referred health care provider, or an insured who does not assign benefits by completing the NY AOB form. To submit a dispute to the IDRE, complete the application found at NYS IDR Provider and Insurer Application.

If you have questions, please call the member phone number on your health plan ID card.