NY Ins L §4903(b)(1)

August 8, 2021 9:45 am Published by

(b)(1) A utilization review agent shall make a utilization review determination involving health care services which require pre-authorization and provide notice of a determination to the insured or insured’s designee and the insured’s health care provider by telephone and in writing within three business days of receipt of the necessary information.  To the extent practicable, such written notification to the enrollee’s health care provider shall be transmitted electronically, in a manner and in a form agreed upon by the parties.  The notification shall identify:  (i) whether the services are considered in-network or out-of-network;  (ii) whether the insured will be held harmless for the services and not be responsible for any payment, other than any applicable co-payment, co-insurance or deductible;  (iii) as applicable, the dollar amount the health care plan will pay if the service is out-of-network;  and (iv) as applicable, information explaining how an insured may determine the anticipated out-of-pocket cost for out-of-network health care services in a geographical area or zip code based upon the difference between what the health care plan will reimburse for out-of-network health care services and the usual and customary cost for out-of-network health care services.

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