Timely Claims, Bills & Denials

Written proof of claim for health service expenses must be submitted as soon as reasonably practicable and no later than 45 days after the date services are rendered (11 NYCRR 65-1.1; for self-insurers, 11 NYCRR 65-2.4(c)). Proof of claim for lost earnings and other necessary expenses is due within 90 days after the loss is incurred (11 NYCRR 65-1.1). The limits apply unless the claimant submits written proof providing clear and reasonable justification for the failure to comply, and any denial for lateness must say that late notice will be excused on reasonable justification (11 NYCRR 65-3.3(e)).

The insurer may deny it as untimely on the NF-10 within 30 calendar days after receipt (11 NYCRR 65-3.8(c)), and the denial must advise that late submission will be excused where the applicant provides reasonable justification (11 NYCRR 65-3.3(e)). The provider then submits written proof providing clear and reasonable justification for the delay (11 NYCRR 65-1.1). Insurers must give appropriate consideration to emergency care providers, difficulty identifying the insurer, and submission to the wrong insurer, with supervisory review of every late-proof denial (11 NYCRR 65-3.5(l)). A lost-wage claim may not be denied as late when the employer or another third party failed to provide the information (11 NYCRR 65-3.5(m)).

No. The 45-day limit applies to proof of claim for health service expenses. Proof of claim for work loss and other necessary expenses is due within 90 days after the loss is incurred (11 NYCRR 65-1.1). Separate from both, written notice of the accident must be given within 30 days after the accident, and a provider cannot cure a missed 30-day notice by submitting bills within 45 days (New York & Presbyt. Hosp. v Country-Wide Ins. Co., 17 NY3d 586 (2011)). Each limit yields only to written proof of clear and reasonable justification (11 NYCRR 65-1.1).