No-Fault Compliance Advisory for Providers

Four kinds. Eligibility: a provider that fails a licensing requirement needed to perform the service, or a professional corporation actually controlled by unlicensed people, is not eligible for reimbursement. Timing: proof of claim later than 45 days after the service without a reasonable justification. Paperwork: no valid assignment, or requested verification in your control neither supplied nor answered with a written reasonable justification within 120 days. Amount: charges above the fee schedule, absent unusual procedures or unique circumstances. Medical necessity is decided claim by claim on the records.

No practice can stop an insurer from making an allegation. What helps is a practice that is what its papers say it is: licensed professionals who actually own and control it, records that match each bill, bills sent on time at fee-schedule rates, and prompt, truthful answers to verification and EUO requests. Do not alter or back-date records. If an insurer alleges fraud, the allegation still has to be proved.

For each claim: the assignment, each bill with proof of the date it was sent, the treatment records behind each charge, verification requests with your dated replies, EUO and examination notices and transcripts, and every denial with the date received. For the practice: licences, the corporate and ownership records, and any management, lease or billing-company agreements. Our healthcare providers page lists the claim file row by row.

First identify who is asking and under what rule. For an insurer’s verification request, supply what is in your control or possession, or a written reasonable justification, within 120 days of the first request; that rule does not cover NF forms, EUOs or medical examinations, which have their own rules. A request from a State agency or law enforcement is a different matter; get advice before responding. In every case, keep a copy of what was asked, what you sent and when.

Not as a general audit. The no-fault endorsement lets an insurer require EUOs “as may reasonably be required”, and the regulation treats an EUO as verification to establish proof of claim: it must rest on objective standards with specific objective justification, at a reasonably convenient time and place. Questions about ownership, control and billing can still be relevant to eligibility. Our EUO page explains the sequence and how to prepare.

Written proof of claim for health services is due no later than 45 days after the date the services are rendered, not 45 days from the first visit. A late bill can still be paid if written proof gives a clear and reasonable justification, and a denial for lateness must tell you that. The insurer’s 30 days to pay or deny generally run once it has the claim and all relevant verification it properly requested.

No practice can guarantee that an insurer or arbitrator will agree. Necessity is decided on the records for each service, so the record should show why the service was needed when it was given: the findings, the plan and the response to treatment. If a denial relies on an IME or peer review report, ask for the report in writing; the insurer must release it on request.

Not under the eligibility regulation alone. In Government Employees Ins. Co. v Mayzenberg (2025), the Court of Appeals held that an insurer may not deny a licensed provider’s claims for alleged professional misconduct, such as paying for referrals, unless it amounts to surrendering control to unlicensed people or the licence is suspended, revoked or annulled. Insurers can still contest medical necessity and sue for damages, and referral payments can carry professional consequences.

Retention periods for treatment records come from your profession’s own record-keeping rules, which this page does not state. For no-fault purposes, keep the full claim file at least until every bill on it is paid or finally resolved, including any arbitration, master arbitration review or court action, and keep the practice’s licensing and ownership records for as long as claims from that period could be questioned.

Find out who is investigating and what they asked for. An insurer’s inquiry runs through verification, EUOs, denials and sometimes a civil lawsuit. A State process to remove a provider’s authorization to bill no-fault must give notice and an opportunity to be heard under Insurance Law 5109. A criminal investigation needs criminal defense counsel. We can review how the inquiry affects your no-fault claims.

It settled the reach of 11 NYCRR 65-3.16(a)(12). The Court of Appeals agreed with DFS that the rule covers foundational licensing requirements needed to perform the service, and control by unlicensed people, but not professional-misconduct claims against a properly licensed provider short of that. It did not change necessity defenses, fee-schedule limits or the insurer’s right to sue. The published slip opinion was marked subject to revision.