Key Takeaway
New York no-fault case shows how healthcare providers can justify failure to comply with insurance verification requests during claims processing.
Understanding Verification Request Compliance in No-Fault Claims
In New York’s no-fault insurance system, healthcare providers must navigate complex verification requirements when submitting claims. Insurance companies routinely request additional documentation to verify claims, and providers’ responses can make or break their ability to recover payment. A recent Appellate Term decision highlights a crucial but often overlooked aspect of this process: the ability to provide reasonable justification for non-compliance with verification requests.
The case demonstrates how providers can potentially avoid claim denials even when they cannot fully comply with every verification request, provided they can articulate proper justification during the claims processing stage.
Jason Tenenbaum’s Analysis:
Burke Physical Therapy, P.C. v State Farm Mut. Auto. Ins. Co., 2022 NY Slip Op 50623(U)(App. Term 2d Dept. 2022)
“While defendant’s claims specialist stated that defendant had not received any of the documents that defendant’s verification requests sought to obtain, plaintiff’s owner merely stated that he had mailed the requested verification “to the extent such response was proper and in possession.” Thus, [*2]plaintiff failed to demonstrate that it had provided the requested verification or had set forth a reasonable justification for the failure to comply with defendant’s verification requests (see 11 NYCRR 65-3.8 ). Consequently, we find no basis to disturb the order”
That underline passage is important. If performed during the claims processing stage and the basis is properly articulated, the App. Term may go along with it,“
Key Takeaway
Healthcare providers don’t always need to provide every document requested in insurance verification demands. However, they must either comply fully or provide reasonable justification for non-compliance during the initial claims process, not after litigation begins. Vague responses about mailing documents “to the extent proper” won’t suffice.
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Common Questions
Frequently Asked Questions
What is New York's no-fault insurance system?
New York's no-fault insurance system requires all drivers to carry Personal Injury Protection (PIP) coverage. This pays for medical expenses and lost wages regardless of who caused the accident, up to policy limits. However, you can only sue for additional damages if you meet the 'serious injury' threshold.
