Key Takeaway
Expert guide to NY no-fault insurance additional verification requirements. Learn compliance strategies and legal protections. Call 516-750-0595.
Understanding Additional Verification Requirements in New York No-Fault Insurance
Additional verification requests represent one of the most complex areas of New York no-fault insurance law, often creating confusion for healthcare providers and patients alike. Recent court decisions, including the significant ruling in New Horizon Surgical Ctr., LLC v Travelers Ins. Co., have clarified important aspects of how insurance companies can delay claim payments through verification demands.
As experienced New York personal injury attorneys who regularly handle no-fault insurance disputes, we understand the frustration providers experience when dealing with additional verification requirements that seem designed to delay rightful payments.
The New Horizon Decision: A Landmark Ruling
In New Horizon Surgical Ctr., LLC v Travelers Ins. Co., 2019 NY Slip Op 51690(U)(App. Term 2d Dept. 2019), the court made a definitive statement about partial responses to verification requests:
“Contrary to plaintiff’s contention, defendant was not required to pay or deny plaintiff’s claims upon receipt of a ‘partial response’ to defendant’s verification requests (see 11 NYCRR [*2]65-3.8 ; ; New York & Presbyt. Hosp. v Progressive Cas. Ins. Co., 5 AD3d 568, 570 [‘A claim need not be paid or denied until all demanded verification is provided’]).”
This ruling has significant implications for healthcare providers and their approach to responding to verification demands.
Legal Framework: 11 NYCRR 65-3.8 Requirements
The 30-Day Rule and Verification Demands
Under New York’s no-fault insurance regulations, specifically 11 NYCRR 65-3.8, insurance companies have specific obligations regarding claim processing:
- 30-day payment requirement: Claims must generally be paid or denied within 30 days of submission
- Verification exception: This timeline can be extended through proper additional verification requests
- Complete response requirement: As New Horizon clarifies, partial responses don’t trigger the obligation to pay or deny
What Constitutes Proper Additional Verification?
The regulations and case law establish several requirements for valid additional verification requests:
- Must be reasonable and related to the claim
- Should be specific and clearly defined
- Cannot be duplicative of information already provided
- Must be legally permissible under HIPAA and state privacy laws
Strategic Implications of the New Horizon Ruling
The Complete Response Standard
The New Horizon decision establishes a clear standard: insurance companies can continue to delay payment as long as any portion of their verification request remains unanswered. This creates both challenges and opportunities for providers.
Challenges for providers:
- Must provide complete, comprehensive responses to all verification requests
- Cannot rely on partial compliance to trigger payment obligations
- Face continued delays if any element is missing or incomplete
Best Practices for Responding to Additional Verification
Comprehensive Documentation Strategy
Based on the New Horizon ruling and established no-fault practice, providers should adopt a comprehensive approach:
- Review each request carefully: Analyze every element of the verification demand
- Provide complete responses: Address every aspect of the request, not just portions
- Document unavailable information: Clearly state when requested information doesn’t exist
- Challenge improper requests: Object to verification demands that are unreasonable or legally improper
- Maintain detailed records: Keep comprehensive records of all verification correspondence
Working with Legal Counsel
Given the complexity of additional verification requirements and the potential for significant payment delays, healthcare providers should consider working with experienced no-fault insurance attorneys who can:
- Evaluate the reasonableness of verification requests
- Craft appropriate responses that satisfy legal requirements
- Challenge improper or excessive demands
- Develop long-term compliance strategies
- Represent providers in disputes and litigation
Frequently Asked Questions About Additional Verification
What happens if I provide a partial response to additional verification?
According to the New Horizon decision, insurance companies are not required to pay or deny claims upon receipt of a “partial response.” You must provide a complete response to all aspects of the verification request to trigger the insurer’s obligation to pay or deny the claim.
Can I object to unreasonable verification requests?
Yes, you can and should object to verification requests that are “palpably improper” or clearly unreasonable. However, you should work with experienced counsel to ensure your objections are properly documented and legally sound.
What if the requested information doesn’t exist?
A complete response stating that certain requested information doesn’t exist or isn’t available can satisfy the verification requirement, provided the response is truthful and comprehensive.
How long can insurance companies delay payment through additional verification?
There’s no specific time limit for additional verification under current regulations. Insurance companies can continue to request additional verification as long as their requests are reasonable and properly made.
Should I use a general compliance affidavit like a Rybak affidavit?
The use of general compliance affidavits in light of the New Horizon decision requires careful consideration. While these affidavits may address some verification requests, they may not constitute a “complete response” to specific, detailed verification demands.
Expert Legal Assistance for No-Fault Verification Disputes
Navigating the complex landscape of additional verification requirements requires sophisticated understanding of both no-fault insurance law and practical compliance strategies. At the Law Office of Jason Tenenbaum, we have extensive experience helping healthcare providers, patients, and other stakeholders address verification-related challenges.
Don’t let complex verification requirements delay your rightful compensation. Contact our experienced team to protect your rights and ensure proper compliance with New York’s evolving no-fault insurance requirements.
Call 516-750-0595 for a free consultation with our experienced New York no-fault insurance attorneys.
Legal Update (February 2026): Since this post’s publication in 2019, the Additional Verification regulations under 11 NYCRR 65-3.8 may have been subject to amendments or clarifying guidance from the New York Department of Financial Services. Additionally, subsequent court decisions may have further refined the interpretation of verification requirements established in the New Horizon case. Practitioners should verify current regulatory provisions and recent case law developments when advising on additional verification procedures and payment obligations.
