Section 3234*3. Explanation of benefits forms relating to claims under certain accident and health insurance policies

(a)  Every  insurer,  including  health  maintenance  organizations  operating  under  article
  forty-four of the public health  law  or  article  forty-three  of  this
  chapter and any other corporation operating under article forty-three of
  this  chapter,  is required to provide the insured or subscriber with an
  explanation of benefits form in response to  the  filing  of  any  claim
  under a policy or certificate providing coverage for hospital or medical
  expenses,  including  policies  and  certificates providing nursing home
  expense or home care expense benefits.
    (b) The explanation  of  benefits  form  must  include  at  least  the
  following:
    (1)  the  name  of  the provider of service the admission or financial
  control number, if applicable;
    (2) the date of service;
    (3) an identification of the service for which the claim is made;
    (4) the provider's charge or rate;
    (5) the amount or percentage payable under the policy  or  certificate
  after  deductibles,  co-payments,  and any other reduction of the amount
  claimed;
    (6) a specific explanation of any denial, reduction, or other  reason,
  including  any  other third-party payor coverage, for not providing full
  reimbursement for the amount claimed; and
    (7) a telephone number or address where an insured or  subscriber  may
  obtain  clarification  of  the  explanation  of  benefits,  as well as a
  description of the time limit, place and manner in which an appeal of  a
  denial of benefits must be brought under the policy or certificate and a
  notification  that  failure to comply with such requirements may lead to
  forfeiture of a consumer's right to challenge  a  denial  or  rejection,
  even when a request for clarification has been made.
    (c) Except on demand by the insured or subscriber, insurers, including
  health  maintenance  organizations operating under article forty-four of
  the public health law or article forty-three of  this  chapter  and  any
  other  corporation  operating under article forty-three of this chapter,
  shall not be required to provide  the  insured  or  subscriber  with  an
  explanation  of  benefits form in any case where the service is provided
  by a facility or provider participating in  the  insurer's  program  and
  full  reimbursement  for  the  claim,  other  than  a co-payment that is
  ordinarily paid directly to the provider at  the  time  the  service  is
  rendered,  is paid by the insurer directly to the participating facility
  or provider.
    (d) This section shall not apply to  medicare  supplemental  insurance
  policies  or  certificates or limited benefits health insurance policies
  or certificates designed primarily to supplement medicare benefits.
    * NB There are 3 § 3234's