Denied No-Fault Benefits for Providers

Start with the ground the insurer states and the date you received the denial. Most grounds fall into a few groups: late proof of claim, medical necessity based on an IME or peer review, fee schedule, missing verification, a missed EUO or examination, eligibility, a coverage or policy issue, or an exhausted policy limit. Each has its own rule and its own evidence, so match the ground to the table on this page before deciding where to file.

For each bill shown to be valid and payable: the amount due, generally at the fee-schedule rate; simple interest at 2% per month on overdue payable benefits, which pauses if you do not file within 30 days after the denial (an interest rule, not a filing deadline); the $40 arbitration filing fee if you prevail; and in most disputes an insurer-paid attorney’s fee, subject to caps and exceptions set out on our collections page. Nothing is guaranteed.

Ask in writing for any IME or peer review report the denial relies on, then compare the ground with your file: proof of mailing, the assignment, verification replies, treatment records and fee-schedule coding. Then choose a route. Arbitration with the American Arbitration Association is an option the insurer must offer; a provider may sue instead. The rules generally require supporting documents with an arbitration request, so assemble them first.

A peer review is a report by a health professional, hired by the insurer, who reviews the records without examining the patient and gives an opinion on medical necessity. If a denial relies on one, the insurer must release a copy on written request. The answer usually comes from the treating records and, where appropriate, a rebuttal from the treating provider that addresses the reviewer’s reasons. The arbitrator or court weighs both.

Sometimes. Time limits for bringing a claim depend on the claim and the forum, and this page does not state them; ask us with the dates in hand. Two rules matter in any case: interest stops accumulating on a denied amount if you did not file within 30 days after receiving the denial, until you file, and the insurer-paid fee and interest still depend on the bill having been overdue or denied when you filed.

Proof of when and how each bill was sent is the answer: mailing logs, certified mail receipts or electronic submission confirmations, kept by claim. If the insurer instead says the bill was late, the rule is 45 days after the date of service, and a denial for lateness must tell you that late notice will be excused with a reasonable justification. Send that justification in writing.

The rules set steps rather than a total. In arbitration: conciliation up to 60 days, the insurer’s response time, a hearing, and an award within 30 days after the hearing or final papers, then a 21-day window for master arbitration. Court actions follow the court’s calendar. Our arbitration page sets out each step and deadline.

That is a clinical and business decision for the practice; the no-fault rules do not require you to stop. Two points to weigh: each new bill is judged on its own records and timing, and you may not ask the patient for payment beyond the authorized charges. If one insurer keeps citing the same ground, fixing the cause in your files usually matters more than the treatment decision.

The no-fault remedies for a late or wrongful denial are the ones in the statute and regulation: payment of benefits found payable, interest at 2% per month on overdue payable benefits and an insurer-paid attorney’s fee within the regulatory limits. This page does not state any separate bad faith damages claim; whether one exists depends on facts beyond an ordinary denial.

Disputes arising from the same accident are to be consolidated where practicable, so bills for one patient’s treatment after one accident can often be heard together. Bills for different patients or accidents are generally separate disputes. Each arbitration request carries its own $40 filing fee, returned by the insurer if you prevail in whole or in part.

Not automatically. The insurer must pay or deny within 30 days after it receives proof of claim, including all relevant verification it properly requested, and a late denial can limit the defenses it may raise. But a late denial based on a lack of coverage does not by itself prevent that defense, and charges above the fee schedule are not payable absent unusual procedures or unique circumstances. Payable benefits that are overdue carry interest.