Why Trust This Analysis
This article is part of our ongoing additional verification coverage, with 205 published articles analyzing additional verification 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.
Healthcare providers submitting claims under New York’s no-fault insurance system face strict compliance requirements that can make or break their reimbursement cases. Two critical areas where providers frequently stumble involve responding to additional verification requests within mandated timeframes and adhering to established fee schedules.
The Crystal Acupuncture case illustrates how courts handle these common disputes. When insurance companies deny claims based on incomplete verification or fee schedule violations, providers must present compelling evidence to overcome these defenses. This case demonstrates the challenges providers face when trying to establish that they properly responded to verification requests or that their billing amounts comply with applicable fee schedules.
Understanding these requirements is essential for healthcare providers operating within New York’s no-fault system, as procedural missteps can result in complete claim denials regardless of the underlying medical necessity of services provided.
Jason Tenenbaum’s Analysis:
Crystal Acupuncture, P.C. v Travelers Ins., 2019 NY Slip Op 52055(U)(App. Term 2d Dept. 2019)
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“With respect to the branches of defendant’s cross motion which sought summary judgment dismissing so much of the complaint as sought to recover upon the claims in the amounts of $281.98, $140.99, $422.97, and $140.99, which claims defendant had denied on the ground that plaintiff had failed to provide requested verification within 120 days of the initial verification requests (see 11 NYCRR 65-3.5 ), defendant demonstrated, prima facie, that it had not received all of the requested verification. Plaintiff failed to raise a triable issue of fact to rebut defendant’s showing.
“With respect to the branches of defendant’s cross motion seeking summary judgment dismissing the unpaid portion of claims which had sought the sums of $1,452.90 and $1,281.91, which defendant had denied on the ground that the amount sought exceeded the amount permitted by the workers’ compensation fee schedule, defendant’s proof was sufficient to establish that defendant had properly paid those claims pursuant to the workers’ compensation fee schedule. In opposition, plaintiff’s affidavit failed to raise a triable issue of fact with respect to those branches of defendant’s cross motion.”
Key Takeaway
This decision reinforces two fundamental principles in no-fault litigation: insurance companies can successfully defend claims by proving non-receipt of verification materials within the 120-day deadline, and providers cannot recover amounts exceeding applicable fee schedules. Healthcare providers must maintain detailed records of their verification responses and ensure billing compliance with established fee schedules to avoid claim denials.
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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
Additional Verification in No-Fault Claims
Under New York's no-fault regulations, insurers may request additional verification of a claim within specified time limits. The timeliness, scope, and reasonableness of verification requests — and the consequences of a claimant's failure to respond — are among the most litigated issues in no-fault practice. These articles examine the regulatory framework for verification requests, court decisions on compliance, and the interplay between verification delays and claim determination deadlines.
205 published articles in Additional Verification
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More Additional Verification Analysis
No Denial Required When Provider Fails to Respond to Verification Within 120 Days
Chapa v MVAIC rejected a 150-day denial deadline, not the need to prove a verification defense. Read the 2026 decision and the historical case directory.
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Acupuncture Reimbursements and Insurance Legalities Explained
Explore the Forrest Chen v. GEICO case and its impact on acupuncture insurance reimbursements in NY. Key insights for providers and patients.
Dec 11, 2024
The denial just has to set forth a fee schedule defense
Court ruling clarifies that insurance companies can raise fee schedule defenses without specific details in denial forms, contrary to recent AAA arbitration trends.
Jun 10, 2016
Evidence insufficient to prove that provider complied with verification request
Pomona v Praetorian: why a third-party biller's affidavit failed to prove a verification response, without requiring an eyewitness to every mailing.
Nov 3, 2013
How did you know that you never received the requested verification?
Eagle Surgical’s August 2010 appeal: timely verification requests did not prove nonreceipt. Read the witness-proof gap and the contrasting October decision.
Aug 19, 2010
CPM – now it is up to DFS and WCB to address the problem
Appellate Division rules CPM reimbursement must be at general public rental value.
Jul 7, 2018Was this article helpful?
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 additional verification 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.
