Key Takeaway
Court rejects healthcare provider's appeal of 45-day rule denial, finding their own papers proved claims were submitted late under 11 NYCRR 65-2.4(c).
New York’s no-fault insurance system operates under strict deadlines designed to ensure prompt processing of claims and prevent fraud. One of the most fundamental requirements is the 45-day rule under 11 NYCRR 65-2.4(c), which mandates that healthcare providers submit their claims to insurance carriers within 45 days of rendering services. This regulation serves as a cornerstone of the no-fault system’s efficiency.
When providers fail to meet this deadline, their claims face automatic denial unless they can demonstrate extraordinary circumstances that warrant due consideration for late notice. However, as the Masigla case demonstrates, some appeals lack merit from the outset.
The challenge for providers lies in understanding that courts scrutinize late submissions carefully. While there are instances where triable issues of fact exist regarding the 45-day rule, providers must ensure their documentation supports their position. When late written notice cannot be excused, the consequences are straightforward: claim denial.
Jason Tenenbaum’s Analysis:
Masigla v ELRAC, Inc., 2017 NY Slip Op 51712(U)(App. Term 2d Dept. 2017)
“With regard to the claims that were denied based upon plaintiff’s failure to submit them to defendant within the time frame required by 11 NYCRR 65—2.4 (c), contrary to plaintiff’s argument on appeal, its own papers demonstrate that the claims were submitted more than 45 days after the dates on which the services had been rendered.”
This was funny.
Key Takeaway
Healthcare providers must carefully review their own documentation before appealing 45-day rule denials. In Masigla, the provider’s appeal was doomed because their own submitted papers proved the claims were filed late. This case highlights the importance of thorough preparation and honest assessment of claim timing before pursuing costly appeals that lack factual support.
