Superintendent of Financial Services Benjamin M. Lawsky has signed the Fourth Amendment to 11 NYCRR 65-3, which will become effective April 1, 2013. The amendment closes the loophole in the regulations that allows claims to remain open indefinitely when verification requested by the insurer is never provided by the applicant and makes it easier to combat overbilling and fraudulent billing for services that were never actually provided. The following is a summary of the amendment:
- New section 11 NYCRR 65-3.5(o) applies to bills for medical services rendered on or after 4/1/13 and claims for lost earnings and reasonable/necessary expenses arising from accidents occurring on or after 4/1/13 and does not apply to verification requests for IMEs, EUOs,or prescribed No-Fault forms. This provision requires the applicant to provide verification requested by the insurer or written proof of a reasonable excuse for failure to comply with the request within 120 days of the initial verification request. Verification requests must advise that failure to comply with the above timeframe may result in denial of the claim.
- New Section 11 NYCRR 65-3.5(p) applies to bills for medical services rendered on or after 4/1/13 and claims for lost earnings and reasonable/necessary expenses incurred on or after 4/1/13. It states that a non-substantive defect in a verification request, or an insurer’s failure to comply with a prescribed timeframe, will not excuse an applicant’s failure to comply with the verification request.
- 11 NYCRR 65-3.8(3) is amended to allow an insurer to deny a claim based upon non-receipt of requested verification within 120 days, provided the verification request includes the advisory required by 11 NYCRR 65-3.5(o) that non-compliance may result in denial.
- New section 11 NYCRR 65-3.8(g), applicable to medical services rendered on or after 4/1/13, states that an applicant has not provided proof of the fact and amount of the loss sustained where the claimed medical services were not provided to an injured party, or the fees claimed are in excess of the fee schedule.
- New section 11 NYCRR 65-3.8(h) applies to medical services, lost earnings, and other reasonable/necessary expenses rendered or incurred on or after 4/1/13 and states that a denial of claim form shall not be invalidated by non-substantive technical or immaterial defects or ommissions.
NOTE – Existing subdivisions (g) through (j) of 11 NYCRR 65-3.8 are re-lettered (i) through (l) to accommodate the new subdivisions.