Key Takeaway
Court rules UB-04 forms alone don't establish prima facie no-fault claims - NF-5 forms required to trigger 30-day payment period under New York insurance law.
This article is part of our ongoing additional verification coverage, with 161 published articles analyzing additional verification issues across New York State. Attorney Jason Tenenbaum brings 24+ years of hands-on experience to this analysis, drawing from his work on more than 1,000 appeals, over 100,000 no-fault cases, and recovery of over $100 million for clients throughout Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, and the Bronx. For personalized legal advice about how these principles apply to your specific situation, contact our Long Island office at (516) 750-0595 for a free consultation.
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.
Legal Context
Why This Matters for Your Case
New York law is among the most complex and nuanced in the country, with distinct procedural rules, substantive doctrines, and court systems that differ significantly from other jurisdictions. The Civil Practice Law and Rules (CPLR) governs every stage of civil litigation, from service of process through trial and appeal. The Appellate Division, Appellate Term, and Court of Appeals create a rich and ever-evolving body of case law that practitioners must follow.
Attorney Jason Tenenbaum has practiced across these areas for over 24 years, writing more than 1,000 appellate briefs and publishing over 2,353 legal articles that attorneys and clients rely on for guidance. The analysis in this article reflects real courtroom experience — from motion practice in Civil Court and Supreme Court to oral arguments before the Appellate Division — and a deep understanding of how New York courts actually apply the law in practice.
About This Topic
Additional Verification in No-Fault Claims
Under New York's no-fault regulations, insurers may request additional verification of a claim within specified time limits. The timeliness, scope, and reasonableness of verification requests — and the consequences of a claimant's failure to respond — are among the most litigated issues in no-fault practice. These articles examine the regulatory framework for verification requests, court decisions on compliance, and the interplay between verification delays and claim determination deadlines.
161 published articles in Additional Verification
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Disclaimer: This article is published by the Law Office of Jason Tenenbaum, P.C. for informational and educational purposes only. It does not constitute legal advice, and no attorney-client relationship is formed by reading this content. The legal principles discussed may not apply to your specific situation, and the law may have changed since this article was last updated.
New York law varies by jurisdiction — court decisions in one Appellate Division department may not be followed in another, and local court rules in Nassau County Supreme Court differ from those in Suffolk County Supreme Court, Kings County Civil Court, or Queens County Supreme Court. The Appellate Division, Second Department (which covers Long Island, Brooklyn, Queens, and Staten Island) and the Appellate Term (which hears appeals from lower courts) each have distinct procedural requirements and precedents that affect litigation strategy.
If you need legal help with a additional verification matter, contact our office at (516) 750-0595 for a free consultation. We serve clients throughout Long Island (Huntington, Babylon, Islip, Brookhaven, Smithtown, Riverhead, Southampton, East Hampton), Nassau County (Hempstead, Garden City, Mineola, Great Neck, Manhasset, Freeport, Long Beach, Rockville Centre, Valley Stream, Westbury, Hicksville, Massapequa), Suffolk County (Hauppauge, Deer Park, Bay Shore, Central Islip, Patchogue, Brentwood), Queens, Brooklyn, Manhattan, the Bronx, Staten Island, and Westchester County. Prior results do not guarantee a similar outcome.
