When it comes to filing insurance claims for services received at an urgent care center, there are a few steps you should take to ensure that the process goes as smoothly as possible. First, consult the information that your doctor and other health professionals should provide to you and the information that your hospital should provide to you for a list of information that should be provided to patients. This will help you understand what services are covered by your health plan and what costs you may be responsible for. HMOs and insurers (health plans) that offer comprehensive health insurance coverage subject to New York law (coverage that is not self-insured) must cover certain services. You can only bill your patient for shared expenses within the network (copay, coinsurance, or deductible), a surprise bill at a hospital or ambulatory surgery center, or a surprise bill when your patient has received a referral.
It's important to note that it is NOT a surprise bill if you choose to receive services from an out-of-network provider instead of one available within the network before going to the hospital or ambulatory surgery center. Decisions regarding insurance claims will be made by a reviewer with training and experience in billing and reimbursement of health care, in consultation with a licensed physician who practices the same or a specialty similar to that of the doctor providing the service that is the subject of the dispute. When filing an insurance claim, make sure to indicate the date (s) of the service, as different laws and processes may apply depending on when you received the services. In addition, consumers with health insurance coverage provided by an insurer or an HMO are protected from receiving unexpected bills when a participating doctor refers them to a non-participating provider. In such cases, your patient can challenge the amount of the bill through New York State's independent dispute resolution process. Health care providers (including hospitals) who are not part of a health plan's network can challenge the amount that the health plan pays them for emergency services at a hospital, including payment for inpatient services following an emergency room visit, through New York State's independent dispute resolution process. You only have to pay shared in-network costs (co-pay, coinsurance and deductible) for bills for out-of-network emergency services at a hospital. If you don't have insurance, or are insured but don't plan to file a claim with your health plan, health care providers must provide you with a good faith estimate of what the expected charges will be before you receive health care services.
To be eligible, services must be provided by a doctor at a hospital or ambulatory surgical center and you will not receive all the required information about your care. If your health plan confirms a denial for reasons of medical necessity, an experimental or investigational treatment, a clinical trial, a treatment for rare diseases, an out-of-network service (if your doctor submitted the required information to your health plan), or an out-of-network referral (if your doctor submitted the required information to your health plan), you have the right to an external appeal. New York consumers are also protected from bills for emergency services in hospitals, including hospital care after treatment in the emergency room. If you are an out-of-network provider who provided emergency services in a hospital, including inpatient services after an emergency room visit, you are prohibited from billing a patient for any amount that exceeds the costs shared within the network (copay, coinsurance, or deductible).