Know Your Rights, Ask Questions!

The Law in New York protects SWSCHP members from surprise out-of-network bills.

As of July 1, 2015 protections were established for individuals if they are confronted with surprise out-of-network charges under the following scenarios in NYS:

  1. A procedure at a hospital/surgery center is in-network but care was received from a doctor who does not participate in SWSCHP’s BlueCross/BlueShield Network because: a participating doctor was not available; you did not know you were getting care from a non-participating doctor, or a medical need that you or your doctor(s) did not expect required you to get care from a non-participating doctor.

  2. You were referred by a participating doctor to an out-of-network provider (including labs) and you did NOT sign consent to show you understood there may be extra cost to you. A referral occurs when you get care from a non-participating provider in the same office, during your visit to the participating doctor; or the participating doctor takes a specimen (example: blood or tissue sample) that is sent to a non-participating lab or pathologist.

IT IS NOT A ‘SURPRISE BILL’ IF YOU CHOOSE TO RECEIVE SERVICES FROM A NON-PARTICIPATING PROVIDER WHEN A PARTICIPATING ONE IS AVAILABLE, OR IF YOU SIGNED A CONSENT FORM AT THE TIME OF REFERRAL TO A NON-PARTICIPATING PROVIDER.

If you believe that you received a ‘surprise bill’ you can obtain the assignment of benefits form here. Your provider is also supposed to provide this form to you at the time of billing you. Send the assignment of benefits form and a copy of the bill that you think is a “surprise bill” to both your provider and the SWSCHP address below. You should outline the reason you believe this is a “surprise bill” and indicate the amount, if any, that you paid the provider.

SWSCHP
Care Navigators at Amalgamated Employee Benefits Administrators (AEBA)
PO Box 5035
White Plains, NY 10602-5035

swschp@amalgamatedbenefits.com

Your completed forms will tell SWSCHP that you want the out-of-network provider who treated you to bill SWSCHP instead of you. If it is truly a ‘surprise bill’, you will be notified, and then you will only be responsible for your in-network co-payment. If you require assistance, call your Care Navigator at 1 888 P-SWSCHP (1-888-779-7247).

Additional information from NYS on Surprise Out-of-Network billing can be found here.