The amendments to the regulations and what they mean to you.

New York’s Fourth Amendment to Regulation 68-C took effect on April 1, 2013. It added the qualified 120-day verification rule, addressed certain defects in requests and denials, and specified treatment of services not provided and fees above permitted charges. The provisions do different jobs and do not share identical applicability language. This February 2013 note preserves Jason’s initial reaction and connects it to the decisions that followed.

Legal Update — Last reviewed: September 2026. In Chapa Products v MVAIC, 245 AD3d 880 (2026), the Appellate Division rejected a mandatory 150-day deadline for a denial under section 65-3.8(b)(3). The 2013 amendment permits a qualifying denial after more than 120 days; it does not require one within the next 30. Chapa involved a denial and does not hold that a denial is never necessary. See the current verification guide and case library.

Read the applicable date and request type first

For sections 65-3.5(o) and 65-3.8(b)(3), medical-service claims turn on treatment or services rendered on or after April 1, 2013. Lost earnings and reasonable and necessary expenses turn on an accident on or after that date. These provisions expressly exclude prescribed NF-forms, medical examination requests, and examinations under oath.

Sections 65-3.5(p) and 65-3.8(h), addressing request and denial defects respectively, refer to medical services rendered and lost earnings or other reasonable and necessary expenses incurred on or after April 1, 2013. Section 65-3.8(g)‘s service-and-fee provision applies to medical services rendered on or after that date.

Those differences matter in an older file. A pre-April accident does not automatically answer which version governs every medical bill. Conversely, the date a lawsuit was filed does not replace the applicability language. Identify the particular subdivision and the treatment, accident, or expense date that it uses.

Jason’s original February 2013 reaction

These paragraphs record Jason’s initial assessment before the amendment took effect. Two points need clarification before the quotation: the regulation measures 120 days from the date of the initial request, not its receipt, and his references to “repeal” describe the amendment’s effect on a line of decisions. They are not a statement that DFS formally overruled those judgments or erased their relevance to earlier services.

What do they mean to you? Well, claims people are enamored with new “(o)” which allows reserves to be closed after the provider does nothing for more than 120 days following receipt of a verification demand. I consider gratuitously objecting also be the equivalent of doing nothing. There will be arbitration and litigation involving the following:

” …under the applicant’s control or possession or written proof providing reasonable justification for the failure to comply.” Once the blanks are filled in, more informed decisions can be made as to what the 120-day rule really means.

Next, what about the repeal of Fair Price? Pretty simple.

I like the repeal of Mercury v. Encare. The First Department really angered the Department and common sense applied. Insurance Law 5108 is not precludable, or shall we say, proof of claim shall not be established if this statute is violated.

Regarding the issue involving the defective denials… The best way to read and understand this rule is to put it in the context of what it is ameliorating. I would look at every defective denial case that the Appellate courts (mostly Second Department Appellate Division) have held that the denial is defective and hold this provision of he regulation against the holdings. The smart practitioner will get his or her way if they use this provision of the regulation from that vantage point.

The operative language adopted in 2013

The following excerpt preserves the provisions reproduced with the original note, with the run-together “NFForm” label normalized. The authoritative DFS adoption document identifies the amendment as signed January 30, 2013, effective April 1. Its complete text should be used for quotation and citation.

(o) An applicant from whom verification is requested shall, within 120 calendar days from the date of the initial request for verification, submit all such verification under the applicant’s control or possession or written proof providing reasonable justification for the failure to comply. The insurer shall advise the applicant in the verification request that the insurer may deny the claim if the applicant does not provide within 120 calendar
days from the date of the initial request either all such verification under the applicant’s control or possession or written proof providing reasonable justification for the failure to comply. This subdivision shall not apply to a prescribed form (NF-Form) as set forth in Appendix 13 of this Title, medical examination request, or examination under oath request. This subdivision shall apply, with respect to claims for medical services, to
any treatment or service rendered on or after April 1, 2013 and with respect to claims for lost earnings and reasonable and necessary expenses, to any accident occurring on or after April 1, 2013.

(p) With respect to a verification request and notice, an insurer’s non-substantive technical or immaterial defect or omission, as well as an insurer’s failure to comply with a prescribed time frame, shall not negate an applicant’s obligation to comply with the request or notice. This subdivision shall apply to medical services rendered, and to lost earnings and other reasonable and necessary expenses incurred, on or after April 1, 2013.
Paragraph (3) of section 65-3.8(b) is amended to read as follows:
(3) Except as provided in subdivision (e) of this section, an insurer shall not issue a denial of claim form (NYS form N-F 10) prior to its receipt of verification of all of the relevant information requested pursuant to sections 65-3.5 and 65-3.6 of this Subpart (e.g., medical reports, wage verification, etc.). However, an insurer may issue a denial if, more than 120 calendar days after the initial request for verification, the applicant has not submitted all such verification under the applicant’s control or possession or written proof providing reasonable justification for the failure to comply, provided that the verification request so advised the applicant as required in section 65-3.5(o) of this Subpart. This subdivision shall not apply to a prescribed form (NF-Form) as set forth in Appendix 13 of this Title, medical examination request, or examination under oath request.

This paragraph shall apply, with respect to claims for medical services, to any treatment or service rendered on or after April 1, 2013, and with respect to claims for lost earnings and reasonable and necessary expenses, to any accident occurring on or after April 1, 2013.

Subdivisions (g) through (j) of section 65-3.8 are relettered subdivisions (i) through (l) and new subdivisions (g) and (h) are added to read as follows:
(g)(1) Proof of the fact and amount of loss sustained pursuant to Insurance Law section 5106(a) shall not be deemed supplied by an applicant to an insurer and no payment shall be due for such claimed medical services under any circumstances:

(i) when the claimed medical services were not provided to an injured party; or

(ii) for those claimed medical service fees that exceed the charges permissible pursuant to Insurance Law sections 5108(a) and (b) and the regulations promulgated thereunder for services rendered by medical providers.

(2) This subdivision shall apply to medical services rendered on or after April 1, 2013.

(h) With respect to a denial of claim (NYS Form N-F 10), an insurer’s non-substantive technical or immaterial defect or omission shall not affect the validity of a denial of claim. This subdivision shall apply to medical services rendered, and to lost earnings and other reasonable and necessary expenses incurred, on or after April 1, 2013.

What the 120-day provision does—and does not do

The applicant’s obligation and the insurer’s permission to deny should be read together. Section 65-3.5(o) calls for verification under the applicant’s control or possession, or written proof providing reasonable justification, within 120 calendar days from the initial request. The insurer must warn the applicant of the stated consequence. Section 65-3.8(b)(3) then permits a denial after more than 120 days if the condition remains unmet.

An incomplete response is therefore not resolved merely by counting days. Identify what was requested, what was supplied, and what explanation accompanied any omission. Nor does the rule mean that every claim expires automatically on day 120. The notice, scope, applicability, and production-or-justification requirements remain part of the analysis.

New York Manual v Nationwide Affinity (2023) gives a concrete later example. The owner said verification was sent only to the extent he considered the response proper and the records were in his possession. The court found that the provider did not demonstrate complete production or a reasonable justification. The case does not offer a universal list of acceptable excuses.

Why the defect provisions should remain separate

Section 65-3.5(p) concerns the applicant’s obligation to comply with a verification request or notice despite the defects and timing departures it describes. Section 65-3.8(h) concerns non-substantive technical or immaterial defects or omissions in the denial form. The latter does not repeat the former’s language about failure to comply with a prescribed time frame.

That difference is a reason not to summarize the amendment as “all procedural errors are harmless.” A dispute about whether anything was mailed is not automatically an immaterial typo. A dispute about what ground the insurer actually denied is not answered merely by describing a formatting problem. Identify the specific defect and the provision said to address it.

The underlying follow-up schedule still appears in section 65-3.6(b) of the current Regulation 68 compilation: after 30 calendar days with verification unsupplied, follow up within 10 calendar days. The 15-business-day additional-request provision in section 65-3.5(b) addresses the insurer’s request after prescribed forms are received. Neither is a general 15-business-day deadline for a provider’s response.

Services not provided and excess charges

Section 65-3.8(g) addresses proof of loss where claimed medical services were not provided or claimed fees exceed the charges permitted under Insurance Law section 5108 and the implementing regulations. For excess charges, the text addresses the fees above the permitted charges; it is not a statement that an overcharge automatically eliminates every otherwise payable component of a bill.

The provision also requires attention to evidence. An allegation that treatment never occurred is not itself a finding that no service was provided. A fee-schedule position must be tied to the service, permitted charge, and applicable rule. The amendment’s wording supplies the legal issue, not the missing factual proof.

Jason’s contemporary references to Fair Price and Mercury belong to that history. The useful present-day question is which services and rule version the file involves. An old decision about an earlier claim and a regulation governing later services should not be treated as interchangeable without that analysis.

How the cases connect across the amendment

Infinity (2009) considered a three-day-early follow-up and two ignored requests under the former regulation. It shows the pre-amendment dispute over timing consequences. Atlantic Radiology (2018) later addressed an alleged late follow-up where incomplete response was undisputed. Neither case should be turned into a claim that every request is valid regardless of its contents or proof.

The 2017 Lewin note adds a different question: MRI films held by a third party, efforts to obtain them, and the adequacy of the provider’s submissions. That comparison is useful when “not in possession” appears in a response, but its unopposed cross-motion and particular correspondence remain important limits.

Finally, Chapa answered the later disagreement over a mandatory 150-day denial deadline. It did not remove the production-or-justification language. Keeping those developments in sequence makes the original amendment note a reference point for the library, rather than a claim that the entire subject was settled in 2013.

Applying the date distinction to a mixed file

Consider a file with an accident before April 1, 2013 but medical treatment after that date. For the 120-day provision, the medical treatment date is the specified trigger for the medical-service claim. The same provision uses the accident date for a lost-earnings claim. It would be incorrect to resolve both claims solely from the date the insurer opened its file.

Now consider services spanning the effective date. Identify the dates associated with the particular charges instead of describing the entire provider relationship as either “old” or “new.” Section 65-3.8(g), for example, expressly applies to services rendered on or after April 1. A later billing or litigation date is not the substitute stated in that text.

These are illustrations of how to read the applicability clauses, not conclusions about a particular person’s benefits. Other requirements remain to be evaluated. They show why an archive note should preserve the original effective date even while its explanation and links are brought current.

Frequently Asked Questions

What happens if I miss the 120-day deadline?

For a request within the rule’s scope, missing verification without written proof of reasonable justification can support a denial after more than 120 days, provided the required warning was given. The regulation does not make every claim automatically expire on day 120. The actual request, response, and denial need review.

Do these rules apply to all no-fault claims?

No. The 120-day provisions exclude prescribed NF-forms, medical examinations, and examinations under oath. They also distinguish medical-service dates from accident dates for wage and expense claims. The separate defect provisions use their own applicability language, reproduced above.

Can I challenge a denial based on technical defects?

Section 65-3.8(h) protects against the non-substantive technical or immaterial defects and omissions it describes. It does not say every substantive deficiency or timing dispute is harmless. Identify the actual asserted defect before deciding whether that provision answers the objection.

What constitutes “reasonable justification” for missing deadlines?

The rule requires written proof providing reasonable justification; a generic objection is not automatically enough. New York Manual rejected a qualified compliance statement that did not demonstrate production or a sufficient explanation. The opinion does not establish a fixed list of excuses that guarantees acceptance.

How do these changes affect medical providers?

Providers should track the request and response, identify material within their control or possession, and document any explanation for missing verification. The service-and-fee provision also makes the actual treatment and applicable permitted charges important. The amendment does not dispense with factual proof for either side.

Connect to the Encyclopedia

Start with the verification rules and historical case library for the current framework and the cases behind it.

• Infinity: the early follow-up and two unanswered requests
• Atlantic Radiology: an alleged late follow-up with incomplete verification
• New York Manual: partial compliance without a sufficient explanation
• Lewin: third-party MRI films and an objection letter

For review of a particular verification dispute, see our New York no-fault defense practice or contact the firm about the request, response, and claim record. Please do not send medical records or sensitive identifiers through an unverified channel.