Surprise BillOut-Of-Network

InformationSurprise Bill for Healthcare 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 healthcare 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 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. 

A Referral To A Non-Participating Provider Occurs When:

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.

• 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 healthcare 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.

Emergency Services

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

Healthcare Providers for Disputes with a Health Plan Involving an Insured Patient. To submit a dispute, healthcare 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.

Out-of-Network Information

*Usual, Customary and Reasonable (UCR) charges. The amount determined by MetroPlus Health Plan that is reasonable for a particular service in your local area.

For more information, please go to the NY State Department of Financial Services (DFS) website.

*Source: NY State Department of Financial Services