The By Report paradigmNovember 25, 2018

Pavlova v Allstate Ins. Co., 2018 NY Slip Op 51654(U)(App. Term 2d Dept. 2018)

“Plaintiff properly argues that where, as here, a provider does not provide such documentation with its claim form, and the insurer will not pay the claim as submitted, 11 NYCRR 65-3.5 (b) requires the insurer to, within 15 business days of its receipt of the claim form, request “any additional verification required by the insurer to establish proof of claim” (see Bronx Acupuncture Therapy, P.C. v Hereford Ins. Co., 54 Misc 3d 135[A], 2017 NY Slip Op 50101[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2017]). Thus, defendant’s denial of payment for the services billed under CPT code 20999 on the ground that plaintiff had failed to provide sufficient documentation, where defendant did not demonstrate that it had requested any such documentation, was not proper and the branch of defendant’s cross motion seeking summary judgment dismissing so much of the complaint as sought to recover for services billed under that CPT code should have been denied.”

This is an interesting case since several arbitrators have been lulled into finding that Bronx Acupuncture stands for the proposition that an insurance carrier ma not re-price a code labelled “BR” without resort to verification.  Bronx Acupuncture means what it says – you cannot deny a bill based upon the non-compliance with the by report requirements.  Should the carrier believe it has sufficient information to re-price a service, then this defense will stand despite not following the by-report protocols.  Yet, we shall still see too many arbitrators refusing to follow the law.