From the Appellate Term, 2nd Department.
In short, insurers don’t have to seek verification solely from the plaintiff. However, they do have to inform the plaintiff if that first attempt is unsuccessful. A better definition of “applicant” in this context would have been nice.
Doshi Diagnostic Imaging Servs. v State Farm Ins., 2007 NYSlipOp 27193
Where verification is sought from a party other than the applicant, the applicant is entitled to be timely informed of the nature of the verification sought and from whom it is requested when, after an initial verification request remains unsatisfied, a follow-up request is necessary (see 11 NYCRR 65-3.6 [b]).
Elmont Open MRI & Diagnostic Radiology, P.C. v State Farm Ins., 2007 NYSlipOp 50988(U)
In this action by a provider to recover assigned first-party no-fault benefits for an MRI provided its assignor, the court denied plaintiff’s motion for summary judgment and denied defendant’s cross motion for summary judgment on the ground that defendant’s peer review report created a triable issue of the MRI’s medical necessity. After receiving plaintiff’s claim, defendant informed plaintiff by letter that the claim’s “processing” would be delayed pending receipt of “confirmation of medical necessity from the referring physician.” Defendant received the verification 13 days later and issued its denial 30 days thereafter on the basis of the peer review report which was compiled, in part, on information received from the physician.
Plaintiff objects only to defendant’s failure to seek the verification directly from plaintiff as, plaintiff insists, the regulations require. The court below rejected the argument and we affirm for the reasons set forth in Doshi Diagnostic Imaging Servs. v State Farm Insurance.