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45 Day Rule

In order to be eligible to receive No-Fault benefits, does a medical provider have an obligation to send/mail medical bills to an insurance carrier in a timely manner? 

The answer is yes. A Medical provider must submit medical billing to the insurance carrier within 45 calendar days from the date of service. The medical provider must include the date of service when counting the 45 Days.

Pursuant to the Mandatory Personal Injury Protection Endorsement contained in 11 NYCRR §65-1.1 ;

“Proof of Claim; Medical, Work Loss, and Other Necessary Expenses. In the case of a claim for health service expenses, the eligible injured person or that person’s assignee or representative shall submit written proof of claim to the Company, including full particulars of the nature and extent of the injuries and treatment received and contemplated, as soon as reasonably practicable but, in no event later than 45 days after the date of services are rendered… The foregoing time limitations for the submission of proof of claim shall apply unless the eligible injured person or that person’s representative submits written proof providing clear and reasonable justification for the failure to comply with such time limitation.”

Generally, proof that a medical bill was properly mailed gives rise to a rebuttable presumption that the item was received by the carrier. The presumption may be created by either proof of actual mailing, or proof of a standard office practice or procedure designed to ensure that items are properly addressed and mailed.

If a medical provider cannot verify the billing was sent within 45 calendar days from the date of service, the No-Fault regulations do allow for a provider to present a reasonable justification for the delay. The No-Fault regulations require insurers to process late claims when the excuse that is offered by the medical provider is difficulty in ascertaining the identity of the insurance carrier, or if the medical provider inadvertently submitted the bills to the wrong carrier. The genre of excuses that the regulations contemplated as being justifiable are billing office mistakes such as difficulty identifying the proper carrier.

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