Key Takeaway
Court ruling establishes that a claims representative's affidavit explaining fee calculations using relative values and conversion factors creates sufficient prima facie evidence.
Claims Representative’s Attestation Sufficient for Prima Facie Showing
New York’s no-fault insurance system requires precise documentation when calculating reimbursement amounts for medical services. Healthcare providers and insurers frequently dispute the proper application of fee schedules, particularly regarding how relative values and conversion factors should be applied to specific CPT codes. The Appellate Term’s decision in Renelique v American Trust Insurance Co. addresses a fundamental question: what level of proof is required from an insurance company to establish that it correctly calculated reimbursement amounts under the New York No-Fault Insurance Law?
This case provides important guidance for both providers and insurers navigating fee schedule disputes, especially when dealing with complex calculations involving CPT code methodologies and reimbursement formulas.
Jason Tenenbaum’s Analysis:
Renelique v American Tr. Ins. Co., 2016 NY Slip Op 51526(U)(App. Term 2d Dept. 2016)
“Defendant also submitted an affidavit executed by its no-fault examiner, who described how the fees for the services at issue had been calculated by multiplying the appropriate “relative value” by the appropriate “conversion factor.” Plaintiff’s remaining argument with respect to the coding expert’s affidavit and the specific argument made by plaintiff with regard to CPT code 99244 were not raised in the Civil Court, and are therefore not properly before this court.
With respect to plaintiff’s final argument, which involves CPT code 20553, we find that defendant made a prima facie showing that it had used the assigned relative value for that code to calculate the sum to which plaintiff was entitled to be reimbursed.”
The Court held that an affidavit of a claims representative who averred that a “relative value” multiplied by the “conversion factor” is sufficient to prove the compensable amount.
Key Takeaway
Insurance companies can establish prima facie evidence of proper fee calculation through a claims representative’s affidavit that explains the mathematical methodology used. The court found that describing how relative values were multiplied by conversion factors provides sufficient foundation for reimbursement calculations, even when dealing with complex fee schedule applications.
Legal Update (February 2026): Since this post’s 2016 publication, New York’s no-fault fee schedules and reimbursement calculation methodologies have been subject to regulatory amendments and procedural updates. The evidentiary standards for claims representatives’ attestations regarding fee calculations may have evolved through subsequent appellate decisions or regulatory guidance. Practitioners should verify current provisions in the Insurance Regulations and recent case law regarding prima facie requirements for reimbursement disputes.
