N.Y. Insurance Law Section 3235
Explanation of benefits forms relating to claims under medicare supplemental insurance policies and limited benefits health insurance pol...

§ 3235. Explanation of benefits forms relating to claims under medicare supplemental insurance policies and limited benefits health insurance policies or certificates designed primarily to supplement medicare benefits.

(a)

Every insurer issuing medicare supplement insurance policies or certificates and limited benefits health insurance policies or certificates designed primarily to supplement medicare benefits, including health maintenance organizations operating under article forty-four of the public health law or article forty-three of this chapter and any other corporation operating under article 43 (Non-profit Medical and Dental Indemnity, or Health and Hospital Service Corporations)article forty-three of this chapter, is required to provide the insured or subscriber with an explanation of benefits form in response to the filing of any claim under such policy or certificate.

(b)

The explanation of benefits form must include at least the following:

(1)

the name of the provider of service and the admission or financial control number, to the extent that they are included in the information received on the medicare claim from the medicare carrier or intermediary or from the beneficiary;

(2)

a statement that the name and address of the provider of service, an identification of the service, the amount charged for the service, and the medicare approved amount are specified on the medicare explanation of benefits form to which the claim corresponds;

(3)

the date of service;

(4)

the amount of the benefit payable under the policy or certificate, including, if applicable, any amount exceeding medicare’s approved charge;

(5)

when payment under the policy or certificate is based upon the medicare approved charge and does not include any part of a charge which exceeds the medicare approved charge, a statement that the policy or certificate only provides reimbursement for the difference between the medicare approved charge and the medicare payment, that charges in excess of the medicare approved charge may be subject to limitations pursuant to Public Health Law § 19 (Reasonable charges for medicare beneficiaries)section nineteen of the public health law, that the insured or subscriber has a right to appeal the medicare approved charge by writing to medicare’s carrier or fiscal intermediary, and that the insured or subscriber may be responsible for the amount by which the charge exceeds the medicare approved charge; and

(6)

a telephone number or address where an insured or subscriber may obtain clarification of the explanation of benefits, as well as a description of the time limit, place and manner in which an appeal of a denial of benefits must be brought under the policy or certificate and a notification that failure to comply with such requirements may lead to forfeiture of a consumer’s right to challenge a denial or rejection, even when a request for clarification has been made.

(c)

Except on demand by the insured or subscriber, insurers, including health maintenance organizations operating under article forty-four of the public health law or article forty-three of this chapter and any other corporation operating under article 43 (Non-profit Medical and Dental Indemnity, or Health and Hospital Service Corporations)article forty-three of this chapter, issuing medicare supplement insurance policies or limited benefits health insurance policies or certificates designed primarily to supplement medicare benefits shall not be required to provide the insured or subscriber with an explanation of benefits form in any case where the service is provided by a facility or provider on an assignment basis and the insurer’s reimbursement is paid directly to the facility or provider.

Source: Section 3235 — Explanation of benefits forms relating to claims under medicare supplemental insurance policies and limited benefits health insurance pol..., https://www.­nysenate.­gov/legislation/laws/ISC/3235 (updated Sep. 22, 2014; accessed Apr. 13, 2024).

3201
Approval of life, accident and health, credit unemployment, and annuity policy forms 3202
Withdrawal of approval of policy forms 3203
Individual life insurance policies 3204
Policy to contain entire contract 3205
Insurable interest in the person 3206
Policies which provide for an adjustable maximum rate of interest on policy loans 3207
Life insurance contracts by or for the benefit of minors 3208
Antedating of life insurance policies and burial agreements prohibited 3209
Life insurance, annuities and funding agreements disclosure requirements 3210
Incontestability after reinstatement 3211
Notice of premium due under life or disability insurance policy 3212
Exemption of proceeds and avails of certain insurance and annuity contracts 3213
Payment of proceeds 3214
Interest upon proceeds of life insurance policies and annuity contracts 3215
Disability benefits in connection with life insurance and annuities 3216
Individual accident and health insurance policy provisions 3217
Minimum standards in the form, content and sale of accident and health insurance 3217–A
Disclosure of information 3217–B
Prohibitions 3217–C
Primary and preventive obstetric and gynecologic care 3217–D
Grievance procedure and access to specialty care 3217–E
Choice of health care provider 3217–F
Prohibition on lifetime and annual limits 3217–G
Maternal depression screenings 3217–H
Telehealth delivery of services 3217–I
Essential health benefits package and limit on cost-sharing 3217–J
Utilization review determinations for medically fragile children 3218
Medicare supplemental insurance policies 3219
Annuity and pure endowment contracts and certain group annuity certificates 3220
Group life insurance policies 3221
Group or blanket accident and health insurance policies 3222
Funding agreements 3223
Group annuity contracts 3224
Standard claim forms 3224–A
Standards for prompt, fair and equitable settlement of claims for health care and payments for health care services 3224–B
Rules relating to the processing of health claims and overpayments to physicians 3224–C
Coordination of benefits 3224–D
Prescription synchronization 3225
Eligibility for health insurance in cases of exposure to DES 3226
Reinsurance contracts excepted 3227
Interest upon surrenders, policy loans and other funds 3228
Individual accident and health insurance policies 3229
Minimum benefit standards for certain long term care plans 3230
Accelerated payment of the death benefit or special surrender value under a life insurance policy 3231
Rating of individual and small group health insurance policies 3231*2
Health insurance policies and subscriber contracts 3232
Pre-existing condition provisions in health policies 3232–A
Certification of creditable coverage 3233
Stabilization of health insurance markets and premium rates 3234
Pre-existing condition provisions in group and blanket disability policies 3234*2
Limitations on administrative services and stop-loss coverage 3235
Explanation of benefits forms relating to claims under medicare supplemental insurance policies and limited benefits health insurance pol... 3236
Public health law assessments 3237
Health insurance coverage for full-time students on medical leaves of absence 3238
Pre-authorization of health care services 3239
Wellness programs 3240
Unclaimed benefits 3240*2
Student accident and health insurance 3241
Network coverage 3242
Prescription drug coverage 3243
Discrimination because of sex or marital status in hospital, surgical or medical expense insurance 3244
Explanation of benefits forms relating to claims under certain accident and health insurance policies 3245
Liability to providers in the event of an insolvency
Green check means up to date. Up to date

Accessed:
Apr. 13, 2024

Last modified:
Sep. 22, 2014

§ 3235’s source at nysenate​.gov

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