Sec. 400.7. Process to submit disputes regarding emergency services or surprise bills

(a)

(1) Emergency services. A health care plan, a non-participating physician, a non-participating hospital, or a patient who is not an insured may submit a dispute regarding emergency services, including inpatient services that follow an emergency room visit, to the superintendent for review by an IDRE.

(2) Surprise bills. A health care plan, a non-participating physician, a non-participating referred health care provider, an insured who does not assign benefits, or a patient who is not an insured may submit a dispute regarding a surprise bill to the superintendent for review by an IDRE.

(b) The dispute shall be submitted by completing an application in a form and manner prescribed by the superintendent.

(c) A health care plan shall provide the following information:

(1) the name and contact information of the health care plan;

(2) the name and contact information of the non-participating physician, non-participating hospital, or non-participating referred health care provider;

(3) the fee charged by the non-participating physician, non-participating hospital, or non-participating referred health care provider for the service that is the subject of the dispute, and provide a copy of the bill;

(4) the fee paid to the non-participating physician, non-participating hospital, or non-participating referred health care provider for the service that is the subject of the dispute;

(5) at least three fees paid in the last 24 months by the health care plan to reimburse similarly qualified non-participating physicians, non-participating hospital, or non-participating referred health care providers for the same services in the same region that reflect the final and full payment to the non-participating physician, non-participating hospital, or the non-participating health care provider, if available;

(6) an explanation of the circumstances and complexity of the particular case, including time and place of the service, if available;

(7) individual patient characteristics, if available;

(8) for a dispute involving a non-participating physician, the usual and customary cost for the service, when the benchmarking database contains the usual and customary cost for the service subject to the dispute;

(9) for a dispute involving a non-participating hospital that had previously entered into a participating provider agreement with the health care plan, for emergency services, including inpatient services that follow an emergency room visit, the health care plan’s best and final offer, if different from the payment made pursuant to section 400.5(a)(1)(ii) of this Part, and the non-participating hospital’s best and final offer, if any;

(10) any other information the health care plan deems relevant;

(11) the patient’s coverage type;

(12) an attestation affirming that the information provided by the health care plan is true and accurate; and

(13) any information requested by the IDRE.

(d) A non-participating physician, non-participating hospital, or non-participating referred health care provider shall provide the following information:

(1) the name and contact information of the physician, hospital, or non-participating referred health care provider;

(2) the name and contact information of the health care plan;

(3) the fee charged by the physician, hospital, or non-participating referred health care provider for the service that is the subject of the dispute and a copy of the bill;

(4) the fee paid to the physician, hospital, or non-participating referred health care provider for the service that is the subject of the dispute;

(5) at least three fees paid to the physician, hospital, or non-participating referred health care provider, in the last 24 months for the same services rendered by the physician, hospital, or non-participating referred health care provider to other patients in health care plans in which the physician, hospital, or non-participating referred health care provider is not participating that reflect the final and full payment to the non-participating physician, non-participating hospital, or the non-participating health care provider, if available;

(6) the physician’s, hospital’s, or non-participating referred health care provider’s usual charge for comparable services rendered to other patients in health care plans in which the physician, hospital, or non-participating referred health care provider is not participating;

(7) the physician’s or non-participating referred health care provider’s level of training, education and experience;

(8) for a dispute involving a non-participating hospital, the non-participating hospital’s teaching status, scope of services, and case mix;

(9) an explanation of the circumstances and complexity of the particular case, including time and place of the service;

(10) individual patient characteristics;

(11) any other information the physician, hospital, or non-participating referred health care provider deems relevant;

(12) an attestation affirming that the information provided by the physician, hospital, or non-participating referred health care provider is true and accurate; and

(13) any information requested by the IDRE.

(e) Patients submitting the dispute shall provide the following information:

(1) the name and contact information of the patient;

(2) the name and contact information of the physician, hospital, or non-participating referred health care provider;

(3) the name and contact information of the health care plan, if the patient is an insured;

(4) the fee charged by the physician, hospital, or non-participating referred health care provider for the service that is the subject of the dispute and a copy of the bill;

(5) an explanation of the circumstances and complexity of the particular case, including time and place of the service;

(6) individual patient characteristics, if available;

(7) any other information the patient deems relevant;

(8) a consent to the release of medical information;

(9) with respect to a patient who is not an insured and who requests a waiver of the fee based hardship, information to demonstrate that the patient is eligible for a hardship exemption;

(10) with respect to a patient who is not an insured and who submits a dispute for a surprise bill, a statement that the required disclosures have not been provided;

(11) an attestation affirming that the information provided by the patient is true and accurate; and

(12) any information requested by the IDRE.

(f) A patient shall not be required to pay the physician’s, hospital’s or non-participating referred health care provider’s fee in order to be eligible to submit the dispute for review to an IDRE.

(g) A health care plan, physician, hospital, non-participating referred health care provider or patient shall provide any information requested by an IDRE as soon as possible, but no later than the timeframe requested by the IDRE, as provided under section 400.8 of this Part.