N.Y. Comp. Codes R. & Regs. Tit. 11 §§ 217-2.1

Current through Register Vol. 46, No. 50, December 11, 2024

Section 217-2.1 - Definitions and applicability

(a) For purposes of this Subpart:

(1) Coordination of benefits or COB means a procedure that is intended to avoid claims payment delays and duplication of benefits when a person is covered by two or more health insurers providing benefits or services for medical, dental or other care or treatment by: establishing an order in which plans pay their claims, providing the authority for the orderly transfer of information needed to pay claims properly and permitting a reduction of the benefits of a health insurer when, by the rules established by section 52.23 of this Title (Regulation No. 62), it does not have to pay its benefits first.

(2) Health care claim means a request for payment for services rendered to an insured pursuant to the benefits provided in a health insurance policy.

(3) Health care provider means an entity licensed or certified pursuant to article 28, 36 or 40 of the Public Health Law; a facility licensed pursuant to article 19, 23 or 31 of the Mental Hygiene Law; a health care professional licensed, registered or certified pursuant to title 8 of the Education Law; or a health care provider comparably licensed, registered or certified by another state; or a dispenser or provider of pharmaceutical products, services or durable medical equipment.

(4) Health insurance policy means a contract that provides benefits or services for medical, dental or other health care or treatment.

(5) Health insurer means an insurer that issues a health insurance policy.

(6) Remittance advice means a form on which a health insurer indicates to a health care provider the details of the health insurer's processing of a particular claim.

(7) Primary health insurer means a health insurer whose benefits for a person's health care coverage must be determined without taking the existence of coverage issued by any other health insurer into consideration, pursuant to the COB rules in section 52.23 of this Title and the provisions of the health insurer's policy or contract.

(8) Secondary health insurer means a health insurer that is not a primary health insurer that may take into consideration the benefits of the primary health insurer or insurers and the benefits of any other accident and health coverage.

(b) This Subpart shall apply to a health insurer authorized to write accident and health insurance pursuant to article 42 of the New York Insurance Law, a corporation licensed pursuant to article 43 of the Insurance Law, or an entity certified pursuant to article 44 of the Public Health Law, with respect to a health care claim submitted under a health insurance policy. This Subpart shall not apply to coordination of benefits involving no-fault auto insurance policies, workers compensation polices or the Medicare program.

(c) The requirements of this section shall apply when an individual is covered, or where there is a reasonable basis supported by specific information to believe that the individual is covered, under more than one health insurance policy that provides benefits or services for medical, dental or other care or treatment.

N.Y. Comp. Codes R. & Regs. Tit. 11 §§ 217-2.1