Sound Shore Med. Ctr. v New York Cent. Mut. Fire Ins. Co., 2013 NY Slip Op 02390 (2d Dept. 2013)
“On this appeal, we are asked to determine whether a no-fault UB-04 form is the functional equivalent of a no-fault New York State Form N-F 5 (hereinafter N-F 5 form), the receipt of which triggers the 30-day period in which a no-fault insurer is required to pay or deny a claim for no-fault benefits or request further verification. For the following reasons, we answer in the negative”
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“When a no-fault claim has been assigned to a hospital or medical provider and the hospital or medical provider sends an N-F 5 form to the no-fault insurer, the no-fault insurer’s receipt of an N-F 5 form triggers the running of the 30-day period within which the insurer has a duty to pay or to deny the claim, or to seek verification of it (Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co., 9 NY3d 312, 317). Subsequent to the receipt of the N-F 5 form, if the insurer requires any additional information to evaluate the proof of claim, such request for verification must be made within 15 business days of the receipt of the N-F 5 form in order to toll the 30-day period (see 11 NYCRR 65-3.5[b]; Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co., 9 NY3d at 317)”
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” The “UBF-1 form” referred to in 11 NYCRR 65-3.5(g) is the predecessor of the current “UB-04” form. Under 11 NYCRR 65-3.5(g), a UBF-1/UB-04 form together with an N-F 5 form must be accepted by a no-fault insurer. The regulation does not state that a UBF-1/UB-04 form alone must be treated as the “functional equivalent” of an N-F 5 form.”
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The Appellate Division has now held that the NF-5 is now the loadstar for when the pay or deny clock begins. In other words, when you receive a UB-92, UB-04, UB-01 – this is insufficient. An NF-5 is what is needed when the hospital is the Applicant. Consequently, “verification” of the UB-04/UB-92/UB-01 received prior to the NF-5 is insufficient. Thus, the order of the Appellate Term, Second Department was reversed.
