No-Fault Fee Schedule Defense: NF-10 Denial Form Requirements and Regulation Analysis

New York’s no-fault insurance system requires insurers to pay medical providers for treatment arising from motor vehicle accidents, but only up to the amounts permitted under the applicable fee schedule. The interplay between fee schedule limits, denial form requirements, and evidentiary standards creates a complex landscape for both insurers and providers. The 2016 Civil Court decision in Tyorkin v Garrison Property & Casualty Insurance Co. illustrates several of these tensions — and exposes the kind of sloppy litigation practice that can undermine otherwise valid defenses.

Background: Fee Schedules and Denial Requirements

Under New York’s no-fault regulations, medical providers submit claims for treatment rendered to injured parties. Insurers have 30 days to pay or deny claims, and denials must be issued on the prescribed NF-10 form. Failure to timely deny a claim can preclude the insurer from raising most defenses.

However, the fee schedule operates differently from other defenses. Section 11 NYCRR 65-3.8(g) provides that “no payment shall be due under any circumstances” for medical service fees that exceed the fee schedule amounts. This language creates a statutory cap on reimbursement that exists independently of the denial process. The question in Tyorkin was whether this statutory language truly means what it says — or whether insurers must still comply with the NF-10 denial form requirement before invoking fee schedule limits.

Jason Tenenbaum’s Analysis

Tyorkin v Garrison Prop. & Cas. Ins. Co., 2016 NY Slip Op 50846(U)(Civ. Ct. Kings Co. 2016)

Issue 1: The NF-10 Denial Form and Peer Review Defense

“In the case at bar, Defendant’s affiant, Raina Lira, a Claims Adjuster employed by Defendant, avers that Defendant, through its vendor, Auto Injury Solutions (AIS), mailed the [*2]Explanation of Reimbursement Form (EOR) to the medical provider. There is no indication that a NF-10 form was issued in this matter although Ms. Lira avers that in applicable instances, the Denial of Claim Form (NF-10) is sent. Further, there is no indication that the EOR form, which was the only document issued in response to Plaintiff’s claim, is a form or letter approved by the Department as so allowed by 11 NYCRR 65-3.8(c)(1). Thus, notwithstanding both parties’ arguments with regards to the substantive merits of the peer review defense, the Court finds that such defense is precluded by Defendant’s failure to issue a NF-10 Denial of Claim form.”

Here’s a silly question. Was this is an out of state based policy? Did anyone argue that out of state law applied? The policy mandates arbitration? Alrof, Bright Supply, bad affidavits?

Issue 2: The Fee Schedule Defense Survives Without an NF-10

“Likewise, in this instance, the Court finds that Defendant’s fee schedule defense is neither precluded by timeliness or its failure to issue a Denial of Claim form as the language of the statute strictly mandates that “no payment shall be due .under any circumstances” for medical service fees that exceed the fee schedule charges. 11 NYCRR 65-3.8(g). In other words, [*3]Plaintiff would only be entitled to the payment of the subject bill at the rates permissible and authorized in the state of New Jersey. The Court is unpersuaded by Defendant’s argument that payment for Plaintiff’s bill is outright prohibited simply because the billed amount is higher than permissible. The regulation only reduces payment to the amount authorized by the applicable fee schedule.”

This is an important statement as various arbitrators have taken the position that over-billing is tantamount to failure to provide proof of claim and nothing should be awarded. While inartfully drafted, 65-3.8(g)(iii) sought to overturn Mercury v. Encare, which disallowed the insurance company to raise a fee schedule defense to grossly over-billed services.

Issue 3: Insufficient Evidence for Fee Schedule Calculations

“In Ms. Moreno’s affidavit, upon which she concludes that the proper amount of the bill would be $5,976.50, rather than the billed amount of $10,144.88, there is no further explanation as to what the sum comprises of. While the Court may consider an attorney affirmation in the explanation of fee schedule provisions and the Court may take judicial notice of the fee schedule (see Kingsbrook Jewish Med. Ctr. v Allstate Ins. Co., 61 AD3d 13, 18 ), the attorney affirmation of Dianne Galluzzo neither explains Ms. Moreno’s analysis or explains allowable reductions. The Court cannot presume to be knowledgeable of fee schedule reductions that, on its face, cannot be specifically adduced, and will not make any findings of fact as to such reductions. As such, a triable issue of fact remains as to its fee schedule defense. Further, the Court notes that while Ms. Moreno’s analysis sufficiently raises a triable issue, her analysis alone is inarticulate and insufficient to be the basis of summary judgment.

Very sloppy. There is no quality control over these cases.

Legal Significance

The Tyorkin decision addresses three distinct but interrelated issues that affect no-fault defense strategy in New York:

The NF-10 requirement is real. The court reaffirmed that peer review and medical necessity defenses require proper denial on the NF-10 form. Sending an Explanation of Reimbursement (EOR) from a third-party vendor does not satisfy this requirement unless the form has been approved by the Department of Financial Services. Insurers who rely on vendor-generated correspondence rather than prescribed denial forms risk preclusion of their defenses.

Fee schedule defenses operate independently. Unlike other defenses, the fee schedule cap exists by operation of regulation. The court’s holding that the fee schedule defense survives the absence of an NF-10 reflects the mandatory language of 11 NYCRR 65-3.8(g). This distinction is critical for insurers who may have failed to issue timely denials but still seek to limit reimbursement to fee schedule amounts.

Overbilling reduces — it does not eliminate — the claim. The court rejected the insurer’s argument that billing above the fee schedule amounts should result in complete denial of the claim. Instead, the regulation reduces payment to the permissible amount. As Jason notes, some arbitrators have taken the more extreme position that overbilling constitutes a failure to provide proof of claim, but this court declined to follow that reasoning.

Practical Implications

For insurance carriers and their counsel, the Tyorkin decision contains both a victory and a warning:

• Always issue the NF-10. Relying on EOR forms or vendor correspondence instead of the prescribed denial form is a risk that can result in preclusion of defenses, regardless of their substantive merit.
• Document fee schedule calculations thoroughly. Conclusory affidavits stating a reduced amount without explaining the methodology will not survive scrutiny. Every line-item reduction should be explained with reference to the applicable fee schedule codes and rates.
• Consider out-of-state policy issues. Jason raises the question of whether the policy was out-of-state based and whether anyone argued for application of out-of-state law. These are threshold questions that can change the entire analysis.

For medical providers pursuing no-fault claims, the decision confirms several important protections:

• Overbilling is not fatal. Even if a bill exceeds the fee schedule, the provider is entitled to the permitted amount. Carriers cannot use overbilling as a basis for complete denial.
• Challenge the evidence. When insurers raise fee schedule defenses, demand detailed calculations. Vague or unexplained reductions create triable issues of fact that can defeat summary judgment.
• Verify the denial form. Confirm that the insurer used a proper NF-10 form for any defense other than the fee schedule cap. The absence of a proper denial may preclude the defense entirely.

For personal injury practitioners handling the medical billing component of their cases, understanding these fee schedule nuances can significantly affect recovery for their clients.

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Legal Update (February 2026): Since this post’s publication in 2016, the fee schedule regulations under 11 NYCRR 65-3, including section 65-3.8 governing denial forms and reimbursement procedures, may have undergone amendments or clarifications. The Department of Financial Services has periodically updated fee schedule provisions and claim processing requirements over the past decade. Practitioners should verify current regulatory language and any recent interpretive guidance regarding EOR forms, NF-10 denial requirements, and fee schedule defense procedures.

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