N.Y. Public Health Law 2807-E – Uniform bills
§ 2807-e. Uniform bills. 1. Definitions. For the purposes of this section, unless the context clearly requires otherwise:
Terms Used In N.Y. Public Health Law 2807-E
- General hospital: means a hospital engaged in providing medical or medical and surgical services primarily to in-patients by or under the supervision of a physician on a twenty-four hour basis with provisions for admission or treatment of persons in need of emergency care and with an organized medical staff and nursing service, including facilities providing services relating to particular diseases, injuries, conditions or deformities. See N.Y. Public Health Law 2801
- Health-related service: means service in a facility or facilities which provide or offer lodging, board and physical care including, but not limited to, the recording of health information, dietary supervision and supervised hygienic services incident to such service. See N.Y. Public Health Law 2801
- Hospital: means a facility or institution engaged principally in providing services by or under the supervision of a physician or, in the case of a dental clinic or dental dispensary, of a dentist, or, in the case of a midwifery birth center, of a midwife, for the prevention, diagnosis or treatment of human disease, pain, injury, deformity or physical condition, including, but not limited to, a general hospital, public health center, diagnostic center, treatment center, a rural emergency hospital under 42 USC 1395x(kkk), or successor provisions, dental clinic, dental dispensary, rehabilitation center other than a facility used solely for vocational rehabilitation, nursing home, tuberculosis hospital, chronic disease hospital, maternity hospital, midwifery birth center, lying-in-asylum, out-patient department, out-patient lodge, dispensary and a laboratory or central service facility serving one or more such institutions, but the term hospital shall not include an institution, sanitarium or other facility engaged principally in providing services for the prevention, diagnosis or treatment of mental disability and which is subject to the powers of visitation, examination, inspection and investigation of the department of mental hygiene except for those distinct parts of such a facility which provide hospital service. See N.Y. Public Health Law 2801
- Provider: means an individual or entity, whether for profit or nonprofit, whose primary purpose is to provide professional health care services. See N.Y. Public Health Law 2801
(a) "Ambulatory care services" shall mean ambulatory surgical services, diagnostic and treatment services, emergency services, hospital outpatient services and physician services.
(b) "Superintendent" shall mean the superintendent of financial services.
(c) "Third-party payor" shall mean those payors within the payor categories specified in paragraphs (a) and (b) of subdivision one of section twenty-eight hundred seven-c of this article, except for payments made for persons who are eligible as beneficiaries of title XVIII of the federal social security act (medicare).
(d) "Bill," other than a patient bill, shall include a claim form for a third-party payor.
2. Uniform bills. (a) Notwithstanding any inconsistent provisions of law, the commissioner shall, on or after July first, nineteen hundred ninety-five, develop a uniform patient bill for the purpose of providers providing a health care consumer with a patient bill for hospital and health-related services, in consultation with the superintendent of financial services, statewide organizations representative of providers of hospital and health-related services, third-party payors as described in paragraphs (a) and (b) of subdivision one of section two thousand eight hundred seven-c of this article, and representatives of health care consumers. Such patient bill shall be in such form and shall contain such information as may be required in accordance with rules and regulations developed by the commissioner, provided that distinct uniform patient bills may be developed for each type or level of health-related service.
(b) No provider of hospital or health-related services shall provide a health care consumer with any patient bill, on or after September first, nineteen hundred ninety-five, for services provided to such consumer except such uniform patient bill as developed by the commissioner pursuant to paragraph (a) of this subdivision.
(c) Notwithstanding any inconsistent provision of this article or any other law, beginning on or after April first, nineteen hundred ninety-four, each general hospital providing inpatient services shall use a uniform data set, developed by the commissioner in consultation with representatives of providers and third-party payors, for the purpose of billing a third-party payor for inpatient services containing such information as may be required in accordance with rules and regulations of the commissioner.
(d) Notwithstanding any inconsistent provision of this article or any other law, beginning on or after September first, nineteen hundred ninety-four, each general hospital, diagnostic and treatment center, or ambulatory surgery center providing ambulatory care services shall use a uniform bill, developed by the commissioner in consultation with representatives of providers and third-party payors, for the purpose of billing a third-party payor for ambulatory care services containing such information as may be required in accordance with rules and regulations of the commissioner.
(e) Notwithstanding any inconsistent provision of this article or any other law, beginning on or after January first, nineteen hundred ninety-five, each physician providing physician services shall use a uniform bill, developed by the commissioner in consultation with representatives of providers and third-party payors, for the purpose of billing a third-party payor for physician services containing such information as may be required in accordance with rules and regulations of the commissioner.
(f) Notwithstanding any inconsistent provision of this article or any other law, the commissioner in consultation with the superintendent and the commissioner of social services shall establish procedures for requiring any payor for inpatient services, ambulatory care services or physician services making payment pursuant to the provisions of this section to utilize a uniform bill for patient services required pursuant to paragraphs (c), (d) and (e) of this subdivision.
* 3. Fiscal intermediary. Notwithstanding any inconsistent provision of law, the commissioner shall not enter into an agreement for a pilot program which provides for among its purposes a single fiscal intermediary for the processing of hospital bills in a region, unless the commissioner shall first notify the chairs of the senate and assembly standing committees on health not less than one hundred twenty-days prior to entering into such agreement. Such notification shall include, but need not be limited to, the following:
(a) the source of funding and anticipated expenditures for such program;
(b) the geographic region and participants in such program;
(c) the nature and policy objectives of such program, including its relationship to long range policy objectives, and including but not limited to its relationship to establishing a universal health insurance coverage system;
(d) a discussion of the design, proposed implementation, and time-frames for such program; and
(e) a copy of any proposed agreements or other contractual arrangements relating to the program.
In the event the commissioner subsequently enters into an agreement for such a pilot program the commissioner shall promptly provide a copy of such agreement to such chairs. The commissioner shall report every six months thereafter on the progress of implementation of such program and provide a final evaluation of the program upon its conclusion.
* NB Expired July 1, 2017
4. Electronic transfer of claims information. (a) Claims submitted to third-party payors for payment for inpatient hospital services provided by a general hospital on or after April first, nineteen hundred ninety-four shall be submitted in electronic formats consistent with this section.
(b) Claims for payment made to third-party payors for ambulatory care services provided by a general hospital, diagnostic and treatment center or ambulatory surgery center on or after January first, nineteen hundred ninety-five shall be submitted in electronic formats consistent with this section.
(c) Claims for payment made to third-party payors for physician services on or after July first, nineteen hundred ninety-five shall be submitted in electronic formats consistent with this section.
(d) The provisions of this section shall not apply to claims for payment to third-party payors for which the content, processing and payment thereof are regulated solely by federal law or regulation, provided, however that such third-party payors may voluntarily participate in the electronic submission of claims information.
(e) Consistent with their capabilities hospitals, diagnostic and treatment centers, physicians, other practitioners and third-party payors may be permitted to elect to submit claims information electronically prior to the above dates.
(f) The commissioner shall delay or waive the implementation of this section in particular instances for diagnostic and treatment centers or practitioners and, in consultation with the superintendent, third-party payors where such diagnostic and treatment centers, practitioners or third-party payors have a small volume of services or business.
(g) The commissioner, in consultation with the superintendent and the commissioner of social services, shall establish procedures for requiring third-party payors to accept the electronic submission of claims information for inpatient or ambulatory care services made pursuant to the provision of this section.
5. The commissioner, in consultation with the superintendent, shall make recommendations, to the legislature, by June thirtieth, nineteen hundred ninety-four, for improving the efficiency of processing electronic claims by health care providers and third-party payors; including but not limited, to the use of electronic claims clearing-house.