The By-Report

A By Report designation tells the parties that more information is needed to value a service. It does not answer whether an insurer requested that information properly. In Bronx Acupuncture Therapy v Hereford Insurance Co., decided January 20, 2017, the Appellate Term denied the insurer summary judgment on the disputed services because it failed to demonstrate that it requested the necessary additional verification.

Historical note: Bronx Acupuncture addressed the insurer’s proof concerning the two By Report codes in that case. It did not set a reimbursement rate or eliminate documentation requirements. Current services require the applicable fee schedule; the verification-request provision remains in 11 NYCRR 65-3.5(b).

Last reviewed: September 2026.

Which services were before the court

The provider submitted three claim forms that included 21 sessions of moxibustion billed under code 97039 and one acupressure session under code 99199. The opinion describes both as unlisted services assigned a By Report designation under the workers’ compensation fee schedules then at issue.

Neither code had an assigned relative value in the schedules discussed by the court. Additional documentation was needed to determine reimbursement. The provider had not supplied that documentation with its claim forms.

Hereford moved for summary judgment on the theory that it had fully paid the services according to the applicable schedules. Civil Court granted its motion. The provider limited its appeal to the portions involving those two codes, so the appellate disposition should not be described as reopening every service billed in the action.

The insurer’s missing step

The opinion records that Hereford did not request the necessary additional verification within fifteen business days of receiving the claim forms. The insurer also failed to demonstrate on its motion that it requested the information it needed to review the By Report services.

That was enough to defeat its request for summary judgment dismissing those portions of the complaint. The Appellate Term reversed the order insofar as appealed from and denied those branches of the insurer’s motion.

The result did not award the provider its entire bill. It did not establish a new reimbursement amount or decide that an unlisted service must always be paid at the amount charged. A failed defense motion leaves questions unresolved; it does not supply a missing valuation.

Why “By Report” is not the entire defense

A fee-schedule argument should identify the service, the code and the applicable schedule. For an item requiring more documentation to value, the record must also address the request for that documentation. Citing the designation alone leaves the claims-handling question unanswered.

This is the point of Jason’s original commentary below. He treated the missing report as a verification issue that the insurer needed to address, rather than an automatic reason the bill could never become overdue. His observation should be kept within the decision’s procedural scope: the carrier did not establish entitlement to dismissal on the proof it submitted.

A different case can involve timely requests and a provider that never responds, a partial production, or an actual dispute about how a rate applies. Those differences matter. The archive’s First Aid unbundling note distinguishes a coding defense from separate verification defenses asserted against other bills. The label attached to a defense does not prove its elements.

What to retain in a By Report dispute

The claim file should connect the service billed to the information needed to evaluate it. Keep the original claim forms, any accompanying report, the initial and follow-up requests, and the response. If the carrier contends that the fee has already been paid in full, the payment calculation should identify how that conclusion was reached.

On the provider’s side, a response should make clear which requested information is being supplied. A letter reserving everything that might be proper or possessed can fail to identify either production or a justification, as Burke Physical Therapy illustrates. A general statement about a facility’s record-keeping can present the problem discussed in Excel Surgery.

These are ways to organize the evidence, not an invented list of report contents that Bronx Acupuncture prescribed. The opinion does not reproduce a complete By Report submission template. It also does not establish the current status or valuation of either code for every profession and service date.

Use the correct regulatory period

The fifteen-business-day rule in 11 NYCRR 65-3.5(b) concerns the insurer’s request for additional verification after receipt of completed prescribed forms. It should not be rewritten as a fifteen-business-day period for the provider to respond.

The follow-up process is addressed separately in section 65-3.6(b). Qualifying requests may also implicate the production-or-written-justification framework in sections 65-3.5(o) and 65-3.8(b)(3). Those provisions have warning requirements, effective-date conditions and exclusions; an old By Report case does not replace them.

The 2026 verification guide explains the later Chapa timing decision. Chapa did not determine a By Report rate and should not be used as if it did.

A limited but useful result

Bronx Acupuncture makes the analysis more precise: identify the information needed, determine whether it was requested, and connect the request history to the ground on which dismissal is sought. It does not authorize a provider to ignore a proper request or an insurer to dispense with the verification process.

For a present claim, the service date and governing schedule must be checked separately from this historical opinion. This note provides the litigation sequence and its result, not a current billing recommendation for moxibustion or acupressure.

Jason’s original commentary

The original comments below are retained as historical commentary. The case-specific corrections and later developments are explained above.

I recall prior to heading to a miscellaneous part in Supreme Court with guest visits to Civil Court, Judge Cohen found that a by-report code required compliance in order to make a code compesnsable or a billing overdue.  I believed he was wrong and the Appellate Term confirms.

The famous by-report.  The Court properly held that a by-report is verification issue.  This should not shock anyone; yet, I still see denials and argument based upon the failure to adhere to the by-report guidelines.

Connect to the Encyclopedia

Start with the no-fault verification hub and 2026 Chapa update for the governing framework and case directory. Related case notes:

• NYU Hospital-Tisch: final response dates and timely denial.
• Burke Physical Therapy: a qualified response affidavit.
• Infinity’s 2008 decision and its reversal.
• Excel Surgery: answering the specific requested items.
• Mount Sinai: the NF-5 after a defective UB-04.

For review of a particular no-fault verification dispute, request a Free Case Review. Keep the requests, responses and relevant claim dates available for that review.