Provider And Insurer Application Form - Nys Independent Dispute Resolution For Emergency Services And Surprise Bills Page 2
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219. Individual patient characteristics, or submit when contacted by the IDRE if you want considered:
20. Independent Dispute Resolution Eligibility:
a) For Emergency Services: CPT codes 99281 – 99285, 99288, 99291 – 99292, 99217 – 99220, 99224
– 99226, and 99234 – 99236 are not subject to IDR if the bill does not exceed 120% of UCR and the
fee disputed is $631.72 (for 2016 and adjusted annually for inflation rates) or less.
[ ] Yes eligible
[ ] Not eligible
[ ] Don’t know (Please check one.)
b) For Surprise Bills: Have you obtained an assignment of benefits signed by the patient and did you
send it to the provider/health plan?
[ ] Yes
[ ] No (Please check one.) (If yes, please attach.)
21. Provider applicants, complete the following or submit when contacted by the IDRE:
a) Include a representative sample of at least 3 fees received by the provider in the last 24 months
for the same service, in the same region, from health plans in which the provider does not
participate.
_______________________________________________________________________________
b) The provider’s level of training, education and experience in relation to the service.
_______________________________________________________________________________
c) The provider’s usual charge for similar services when the provider does not participate with the
health plan.
_______________________________________________________________________________
22. Health plan applicants, complete the following or submit when contacted by the IDRE:
a) A representative sample of at least 3 fees paid by the health plan as a final payment in the last
24 months to non-participating physicians who are similarly qualified for the same service in
the same region.
_______________________________________________________________________________
b) The usual and customary cost for the service and the database from which this was derived.
_______________________________________________________________________________
23. To be completed by all applicants.
I attest that the information provided in this application is true and accurate to the best of my
knowledge. I agree to pay the IDR fee in full within 30 days from the date of the decision if I am
the non-prevailing party. If there is a settlement, I agree to pay half of the prorated fee. If I am
the applicant and do not provide information for the IDRE to determine eligibility, the application
will be rejected and I agree to pay a processing fee. If I am a provider and the dispute is for a
surprise bill, I agree I shall not bill the patient except for any applicable copayment, coinsurance
or deductible that would be owed if the patient had utilized a participating provider.
Provider or Health Plan Signature: ___________________________________________________________
Print Name: ______________________________________________________________________________
Date: ____________________________________________________________________________________
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