Why Trust This Analysis
This article is part of our ongoing fee schedule coverage, with 118 published articles analyzing fee schedule 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.
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.
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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.
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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
Fee Schedule Issues in No-Fault Insurance
The New York no-fault fee schedule establishes the maximum reimbursement rates for medical treatment provided to injured motorists. Disputes over fee schedule calculations, coding, usual and customary charges, and the applicability of workers compensation fee schedules to no-fault claims are common. These articles analyze fee schedule regulations, court decisions on reimbursement disputes, and the practical challenges providers face in obtaining appropriate payment under the no-fault system.
118 published articles in Fee Schedule
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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 fee schedule 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.
