Surprise Bill for Health Care Services
At MetroPlus, we work hard to prevent members from receiving Surprise Bills. In general, we do not cover services provided by out-of-network providers. We will only cover services provided by out-of-network providers for emergency services and when prior authorization is obtained and we have approved a specific out-of-network provider. Prior authorization to obtain services from an out-of-network provider will only be approved when MetroPlus determines that we do not have a Participating Provider with the appropriate training and experience to treat your condition. Prior authorization to an out-of-network provider will not be approved for convenience. If you think you need to obtain services from an out-of-network provider, please contact us before obtaining such services.
What You Need to Know To Protect Yourself From Surprise Bills
When You Receive Services From A Non-Participating Doctor At A Participating Hospital Or Ambulatory Surgical Center, the Bill You Receive For Those Services Will Be A Surprise Bill If:
- A participating doctor was not available; or
- A non-participating doctor provided services without your knowledge; or
- Unforeseen medical circumstances arose at the time the health care services were provided.
It will not be a surprise bill if you chose to receive services from a non-participating doctor instead of from an available participating doctor.
Examples of surprise bills include but are not limited to the following:
- If you have your blood drawn in a participating physician’s office and the specimen is sent to a non-participating laboratory without your explicit written consent acknowledging that the participating physician is referring you to a non-participating laboratory and that the referral may result in costs not covered by the MetroPlus Health Plan. The bill would be a surprise bill and would be covered as in-network.
- You are admitted to a participating hospital following emergency services. During that hospital stay, consultation services are provided by specialists who do not participate with MetroPlus Health Plan and either: (1) a participating physician is unavailable; or (2) a non-participating physician renders services without your knowledge; or (3) or unforeseen services arise at the time services are rendered.
- You are admitted to a participating hospital for a scheduled hospital admission. During that hospital stay, consultation services are provided by specialists who do not participate with the MetroPlus Health Plan and either: (1) a participating physician is unavailable; or (2) a non-participating physician renders services without your knowledge; or (3) or unforeseen services arise at the time services are rendered.
Examples of bills that are not surprise bills include but are not limited to the following:
- A participating physician provides you with a list of local laboratories and recommends that you make an appointment to have blood work done.
- A participating provider who is not a physician (for example a speech therapist) refers you to a non-participating provider (for example a durable medical equipment provider).
- You request a referral or authorization to a non-participating provider, the referral or authorization is denied by the MetroPlus Health Plan, and you subsequently obtain the services of the non-participating provider.
- You are admitted to a non-participating hospital. During that hospital stay, consultation services are provided by specialists who do not participate with MetroPlus Health Plan.
When You Are Referred By Your Participating Doctor To A Non-Participating Provider, the Bill You Receive For Those Services Will Be A Surprise Bill If you did not sign a written consent that you knew the services would be out-of-network and would result in costs not covered by your health plan.
A referral to a non-participating provider occurs when:
- During the course of a visit with your participating doctor, a non-participating provider treats you; or
- Your participating doctor takes a specimen from you in the office (for example, blood) and sends it to a non-participating laboratory or pathologist; or
- For any other health care services when referrals are required under your plan.
Protect Yourself From A Surprise Bill. You will be protected from a surprise bill and you will only be responsible for your in-network copayment, coinsurance or deductible if you:
- Sign Form. Sign an assignment of benefits form to permit your provider to seek payment for the bill from your health plan; AND
- Send Form & Bill. Send one copy of the form to your provider and include the bill(s) you do not think you should pay. Also send a copy of the form and bill via hard copy to: MetroPlus Health Plan (Customer Services Exchange Department, 160 Water Street, New York, NY 10038); or electronically by going to the MetroPlus Contact Page.
Select "Submit Surprise Bill Info" in the "I would like to..." drop down, fill in your information and attach your signed AOB form and bill(s) in one document.
Hold Harmless Protections for Insured Patients. MetroPlus Health Plan must protect you from bills for out-of-network emergency services in a hospital. You do not have to pay non-participating provider charges for emergency services (typically for services in a hospital emergency room) that are more than your in-network copayment, coinsurance or deductible. Let MetroPlus Health Plan know if you receive a bill from a non-participating provider for emergency services.
The Independent Dispute Resolution (IDR) Process
Submit A Dispute Through The Independent Dispute Resolution (IDR) Process for Surprise Bills or Emergency Services
Health Care Providers for Disputes with a Health Plan Involving an Insured Patient. To submit a dispute, health care providers must:
- Visit the Department of Financial Services (DFS) website to receive a file number;
- Complete this application; and
- Send the application to the assigned independent dispute resolution entity.
Questions. For help call 1.800.342.3736 or e-mail IDRquestions@dfs.ny.gov.
Find a MetroPlus Participating Provider
MetroPlus Health Plan continuously reviews records of providers and facilities, but there may be changes between updates. Please use your Provider Directory and call in advance prior to any appointments.
Please note that MetroPlus will only pay for out-of-network services when prior authorization is obtained or if the service is an emergency or determined to be related to a "Surprise Bill". If you want to obtain services from an out-of-network provider, please contact us.
Determine UCR* for out-of-network services