* § 604. Criteria for determining a reasonable fee. In determining the appropriate amount to pay for a health care service, an independent dispute resolution entity shall consider all relevant factors, including:

1. (a) whether there is a gross disparity between the fee charged by the provider for services rendered as compared to:

   1. (1) fees paid to the involved provider for the same services rendered by the provider to other patients in health care plans in which the provider is not participating, and
   2. (2) in the case of a dispute involving a health care plan, fees paid by the health care plan to reimburse similarly qualified providers for the same services in the same region who are not participating with the health care plan;
2. (b) the level of training, education and experience of the health care professional, and in the case of a hospital, the teaching staff, scope of services and case mix;
3. (c) the provider's usual charge for comparable services with regard to patients in health care plans in which the provider is not participating;
4. (d) the circumstances and complexity of the particular case, including time and place of the service;
5. (e) individual patient characteristics;
6. (f) the median of the rate recognized by the health care plan to reimburse similarly qualified providers for the same or similar services in the same region that are participating with the health care plan; and

7. (g) with regard to physician services, the usual and customary cost of the service. * NB Effective until August 26, 2026 * § 604. Criteria for determining a reasonable fee. (a) In determining the appropriate amount for a health care plan other than a health benefit plan operated pursuant to article eleven of the civil service law to pay for a health care service, an independent dispute resolution entity shall consider all relevant factors, including:

   1. (1) whether there is a gross disparity between the fee charged by the provider for services rendered as compared to:

      1. (A) fees paid to the involved provider for the same services rendered by the provider to other patients in health care plans in which the provider is not participating, and
      2. (B) in the case of a dispute involving a health care plan, fees paid by the health care plan to reimburse similarly qualified providers for the same services in the same region who are not participating with the health care plan;
   2. (2) the level of training, education and experience of the health care professional, and in the case of a hospital, the teaching staff, scope of services and case mix;
   3. (3) the provider's usual charge for comparable services with regard to patients in health care plans in which the provider is not participating;
   4. (4) the circumstances and complexity of the particular case, including time and place of the service;
   5. (5) individual patient characteristics;
   6. (6) the median of the rate recognized by the health care plan to reimburse similarly qualified providers for the same or similar services in the same region that are participating with the health care plan; and
   7. (7) with regard to physician services, the usual and customary cost of the service.

   8. (b)

      1. (1) In determining the appropriate amount for a health benefit plan operated pursuant to article eleven of the civil service law to pay for a health care service, an independent dispute resolution entity shall select either the health care plan's payment or the non-participating provider's fee depending on which one is closest to the allowed benchmark, provided, however, that the independent dispute resolution entity may choose the health care plan's payment or the non-participating provider's fee if it is not closest to the allowed benchmark if:

         1. (A) the health care plan's payment or the non-participating provider's fee are equally distant from the allowed benchmark; or
         2. (B) the independent dispute resolution entity determines that any of the following information submitted by either party clearly demonstrates that the allowed benchmark is not appropriate:
         3. (i) the level of training, education and experience of the health care professional, and in the case of a hospital, the teaching staff, scope of services and case mix;
         4. (ii) the circumstances and complexity of the particular case, including time and place of the service; or
         5. (iii) individual patient characteristics.

      2. (2) If the independent dispute resolution entity selects the health care plan's payment or the non-participating provider's fee that is not closest to the allowed benchmark, such decision shall not be on the basis of:

         1. (A) whether there is a gross disparity between the fee charged by the provider for services rendered as compared to:
         2. (i) fees paid to the involved provider for the same services rendered by the provider to other patients in health care plans in which the provider is not participating; or
         3. (ii) in the case of a dispute involving a health care plan, fees paid by the health care plan to reimburse similarly qualified providers for the same services in the same region who are not participating with the health care plan;
         4. (B) the provider's usual charge for comparable services with regard to patients in health care plans in which the provider is not participating; or
         5. (C) with regard to physician services, the usual and customary cost of the service.
      3. (3) If an independent dispute resolution entity makes a determination pursuant to subparagraph (B) of paragraph one of subsection (b) of this section, its written decision shall include an explanation of the factors in subparagraph (B) of paragraph one of subsection (b) of this section that demonstrated the health care plan's payment or non-participating provider's fee closest to the allowed benchmark was materially different from the appropriate payment for the health care service.
      4. (4) If the independent dispute resolution entity determines the non-participating provider's fee is a reasonable fee for the services rendered, in no circumstances shall the amount owed by a health care plan exceed the maximum fee.
      5. (5) Notwithstanding the foregoing, disputes involving health care services provided by a physician employed by a general hospital licensed under article twenty-eight of the public health law or such hospital's affiliated medical school, or is part of a group practice that is established as a captive professional services corporation whose shareholders are employees of such hospital, shall be subject to subsection (a) of this section even if paid for by a health benefit plan operated pursuant to article eleven of the civil service law.

   9. (c) No fee for services rendered shall be awarded pursuant to this article:

      1. (1) if the health care plan can demonstrate that it has a contract with the provider or a subsidiary or other entity owned or operated by the provider that is in effect at the time the disputed service or services were provided to provide the same service or services at the same location; or
      2. (2) if the health care plan can demonstrate that a notice of determination for prior authorization has been issued to the patient's health care provider pursuant to section forty-nine hundred three of the insurance law and section forty-nine hundred three of the public health law identifying the health care service or services in dispute as out-of-network, or, for patients covered by a health care plan not subject to section forty-nine hundred three of the insurance law or section forty-nine hundred three of the public health law, if a notice of determination for prior authorization has been issued to the patient's health care provider that includes all of the disclosures set forth in such laws and that clearly identifies the health care service or services in dispute as out-of-network. * NB Effective August 26, 2026 until August 26, 2031 * § 604. Criteria for determining a reasonable fee. In determining the appropriate amount to pay for a health care service, an independent dispute resolution entity shall consider all relevant factors, including:

      3. (a) whether there is a gross disparity between the fee charged by the provider for services rendered as compared to:

         1. (1) fees paid to the involved provider for the same services rendered by the provider to other patients in health care plans in which the provider is not participating, and
         2. (2) in the case of a dispute involving a health care plan, fees paid by the health care plan to reimburse similarly qualified providers for the same services in the same region who are not participating with the health care plan;
      4. (b) the level of training, education and experience of the health care professional, and in the case of a hospital, the teaching staff, scope of services and case mix;
      5. (c) the provider's usual charge for comparable services with regard to patients in health care plans in which the provider is not participating;
      6. (d) the circumstances and complexity of the particular case, including time and place of the service;
      7. (e) individual patient characteristics;
      8. (f) the median of the rate recognized by the health care plan to reimburse similarly qualified providers for the same or similar services in the same region that are participating with the health care plan; and
      9. (g) with regard to physician services, the usual and customary cost of the service. * NB Effective August 26, 2031