A verification that pre-dated receipt of a hospital bill along with a follow-up verification that post-dated the hospital bill are deemed sufficient to toll the 30-day claims determination period. The logic, as far as I can see it, is that the hospital bill is also an NF-5 form (so says the opinion), which is a functional equivalent of the NF-2 form. The Court is saying that as long as a verification corresponds to the receipt of the initial UB-04 (the functional equivalent of the NF-5), it will toll the time to pay or deny bills that are received in the intervening time period. Just note that the Appellate Division in Westchester v. Gmac seems to have held contra on similar facts.
Sound Shore Med. Ctr. v New York Cent. Mut. Fire Ins. Co., 2011 NY Slip Op 50033(U)(App. Term 2d Dept. 2011)
“In support of its cross motion and in opposition to defendant’s motion for summary judgment, plaintiff did not assert that it had never received the initial and follow-up verification requests nor did it assert that it had fully complied with these requests. Plaintiff’s attorney merely argued that since the affidavit of the hospital biller, taken together with the copy of the certified return receipt card, established that defendant had received the bill on December 22, 2008, defendant’s initial verification request, sent on November 26, 2008, pre-dated defendant’s receipt of the bill and was therefore a nullity. However, the record establishes that defendant’s initial verification request was sent to plaintiff after plaintiff had sent, and defendant had received, a UB-04 form, which specified the treatment rendered. The UB-04 form is the successor to the UB-92 form and the functional equivalent of the NF-5 form (see Insurance Department Regulations [11 NYCRR] § 65-3.5 [a], [f]). Accordingly, defendant’s initial verification request was not untimely”
One more observation. I think Westchester v. Gmac was one of the 50 worst decisions to come down against the insurance carriers. There are many reasons I say this.
