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

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 
95-25 Queens Boulevard 
Rego Park, New York 11374 

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.


Independent Dispute Resolution (IDR)

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.

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