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HomeMemberManage Your PlanSurprise Bills

Surprise Bills

A "surprise bill" is when a member receives services from an out-of-network provider at a network facility. Surprise bills can also occur when network providers use out-of-network facilities for services such as blood tests without your knowledge or consent. 

Fidelis Care works hard to protect members against surprise bills. To help in this effort, please remember:

Fidelis Care does not cover services by out-of-network providers, EXCEPT:

  • For emergency services
  • When a request for prior authorization to see an out-of-network provider is approved

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In general, Fidelis Care will grant prior authorization when it is determined there is no participating provider with the appropriate training and experience to treat your condition. Prior authorization is not approved for convenience.

If you think you need to see an out-of-network provider, contact Fidelis Care at 1-888-FIDELIS (1-888-343-3547) TTY: 711 before accepting any services. 

When is it a surprise bill?

Sometimes, Fidelis Care members at network hospitals or ambulatory surgical centers will receive health services from providers who do not participate in the Fidelis Care Network. In this case, the resulting bill is NOT always considered a surprise bill. 

If you go to a network facility, but receive care from an out-of-network provider, it's only a surprise bill if:

  • A participating provider was not available; or 
  • A non-participating provider administered health services without your knowledge; or 
  • Unforeseen medical circumstances arose at the time the healthcare services were provided. 

It is NOT a surprise bill if you chose to receive services from a non-participating provider instead of from an available participating provider. 

Examples of surprise bills

Examples of surprise bills include, but are not limited to, the following:

  • Your blood is drawn in a network provider's office, but the blood is sent to a non-participating laboratory without your explicit written consent. 
  • You are admitted to the hospital. During that hospital stay, consultation services are provided by specialists who do not participate with Fidelis Care, AND either: 
    • a network provider is unavailable; OR 
    • an out-of-network provider administers health services without your knowledge; OR 
    • unforeseen health needs arise at the time services are rendered. 
Referrals to non-participating providers

A referral to a non-participating provider occurs when:

  • During the course of a visit with your network provider, an out-of-network provider treats you; or 
  • Your participating provider 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. 

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 an assignment of benefits form to permit your provider to seek payment for the bill from your health plan; AND
  • 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: 

Fidelis Care 
Attention: Member Services 
25-01 Jackson Avenue 
Long Island City, NY 11101 

Protections for insured patients

Fidelis Care 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 Fidelis Care know if you receive a bill from a non-participating provider for emergency services.


 

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network. “Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan.

Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in- network facility but are unexpectedly treated by an out-of-network provider.

 

 

You are protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of- network provider or facility, the most the provider or facility may bill you is your plan’s in- network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

New York State law prohibits balance billing for emergency services received from an out-of-network provider or at an out-of-network facility. 

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.


If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

 

New York State law prohibits balance billing for covered services when received from an out-of-network provider at an in-network facility. New York State law prohibits most out-of-network providers at in-network facilities from balance billing you unless you (a) sign an assignment of benefits form to permit your provider to seek payment for the bill from your health plan; AND (b) send one copy of the form to your provider and include the bill(s) you do not think you should pay. You would then be responsible for an in-network copay, coinsurance, and/or deductible.

 

 

When balance billing isn’t allowed, you also have the following protections:

  • You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
    • Your health plan generally must:
    •  Cover emergency services without requiring you to get approval for services in advance (prior authorization).
    •  Cover emergency services by out-of-network providers.
    •  Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
    •  Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed , you may contact New York State Department of Financial Services at (800) 342-3736 or email Surprisemedicalbills@dfs.ny.gov, or CMS at 1-800-985-3059.

Visit https://www.cms.gov/nosurprises for more information about your rights under federal law.

Visit https://www.dfs.ny.gov/consumers/health_insurance/surprise_medical_bills for more information about your rights under New York State laws.

 

 

Independent Dispute Resolution (IDR) for Providers

Providers who wish to submit a dispute through the IDR Process for Surprise Bills and Emergency Services must:

Questions. For help call 1-800-342-3736 or email IDRquestions@dfs.ny.gov.