UB-04 + nothing else does not equal Prima Facie

Sound Shore Med. Ctr. v New York Cent. Mut. Fire Ins. Co., 2013 NY Slip Op 02390 (2d Dept. 2013)

“On this appeal, we are asked to determine whether a no-fault UB-04 form is the functional equivalent of a no-fault New York State Form N-F 5 (hereinafter N-F 5 form), the receipt of which triggers the 30-day period in which a no-fault insurer is required to pay or deny a claim for no-fault benefits or request further verification. For the following reasons, we answer in the negative”

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“When a no-fault claim has been assigned to a hospital or medical provider and the hospital or medical provider sends an N-F 5 form to the no-fault insurer, the no-fault insurer’s receipt of an N-F 5 form triggers the running of the 30-day period within which the insurer has a duty to pay or to deny the claim, or to seek verification of it (Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co., 9 NY3d 312, 317). Subsequent to the receipt of the N-F 5 form, if the insurer requires any additional information to evaluate the proof of claim, such request for verification must be made within 15 business days of the receipt of the N-F 5 form in order to toll the 30-day period (see 11 NYCRR 65-3.5; Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co., 9 NY3d at 317)”

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” The “UBF-1 form” referred to in 11 NYCRR 65-3.5(g) is the predecessor of the current “UB-04” form. Under 11 NYCRR 65-3.5(g), a UBF-1/UB-04 form together with an N-F 5 form must be accepted by a no-fault insurer. The regulation does not state that a UBF-1/UB-04 form alone must be treated as the “functional equivalent” of an N-F 5 form.”

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The Appellate Division has now held that the NF-5 is now the loadstar for when the pay or deny clock begins.  In other words, when you receive a UB-92, UB-04, UB-01 – this is insufficient.  An NF-5 is what is needed when the hospital is the Applicant.  Consequently, “verification” of the UB-04/UB-92/UB-01 received prior to the NF-5 is insufficient.  Thus, the order of the Appellate Term, Second Department was reversed.

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Legal Update (February 2026): Since this 2013 post, New York’s no-fault regulations under 11 NYCRR Part 65 have undergone multiple amendments, particularly regarding claim submission requirements, verification procedures, and electronic filing standards. The regulatory framework governing prima facie case establishment and the 30-day payment obligations may have been modified. Practitioners should verify current provisions of 11 NYCRR 65-3.5 and related sections, as well as any updated Department of Financial Services guidance on acceptable claim forms and submission procedures.