Surprise Out of Network Bills
New Law in New York State protects SWSCHP Members from Surprise Out-of-Network Bills
Effective July 1, 2015 there are new protections for SWSCHP members in the event they are confronted with surprise out-of-network charges when they experience either of the following scenarios in New York State:
- A procedure at a hospital or surgery center that is in-network but, care was received from a doctor who does not participate in SWSCHP’s BlueCross/BlueShield Network because;
- A participating doctor was not available,
- You did not know you were getting care from a non-participating doctor, or
- A medical need that you or your doctor(s) did not expect required you to get care from a non-participating doctor.
- You were referred by a participating doctor to an out-of-network provider (including labs) and you did NOT sign consent to show you understood there may be extra cost to you. A referral occurs when:
- You get care from a non-participating provider in the same office, during your visit to the participating doctor.
- The participating doctor takes a specimen (example: blood or tissue sample) that’s sent to a non-participating lab or pathologist.
IT IS NOT A ‘SURPRISE BILL’ IF YOU CHOOSE TO RECEIVE SERVICES FROM A
NON-PARTICIPATING PROVIDER WHEN A PARTICIPATING ONE IS AVAILABLE OR IF YOU SIGNED A CONSENT FORM AT THE TIME OF REFERRAL TO A NON-PARTICIPATING PROVIDER.
If you believe that you received a ‘surprise bill’ you can obtain the assignment of benefits form on the SWSCHP Website (SWSCHP.org) or from the following link: http://www.dfs.ny.gov/insurance/health/OON_assignment_benefits_form.pdf
Your provider is also supposed to provide this form to you at the time of billing you.
Send the assignment of benefits form and a copy of the bill that you think is a “surprise bill” to both your provider and the SWSCHP address below.
You should outline the reason that you believe this is a “surprise bill” and indicate the amount, if any, that you paid the provider.
Care Navigators at AliCare
PO Box 5035
White Plains, NY 10602-5035
Your completed forms will tell SWSCHP that you want the out-of-network provider who treated you to bill SWSCHP instead of you. If it is truly a ‘surprise bill’, you will be notified, and then you will only be responsible for your in-network copayment. If you require assistance, call your Care Navigator at 1 888 P-SWSCHP (1-888-779-7247).
Health plans and providers may submit a dispute to IDR using the DFS portal on the DFS website: