Verification Process in No-Fault Claims

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Verification Process in No-Fault Claims

Verification Process in No-Fault Claims

The verification process in no-fault claims can be an irritating headache. Insurance companies can make demands, and you have no idea how to meet them. Insurers may even request information and records that you do not have.

When you have frustrating requests from an insurance company with no clue how to handle them, turn to The Tadchiev Law Firm, P.C., for the experienced legal help you need.

At The Tadchiev Law Firm, P.C., we have a deep knowledge of the claims system. We understand how overwhelming the process can feel. When you are facing the challenges of a no-fault claim, allow us to take the pressure off you. We intentionally keep a smaller caseload, so we can give your case the attention it needs. Our promise: We will always provide the aggressive advocacy and personalized service that you deserve.

Contact The Tadchiev Law Firm, P.C., today to learn how we can help you through the no-fault verification process.

What to Expect in the No-Fault Verification Process

In a typical verification process, insurance carriers will request documents and other information in support of your no-fault claim. Depending on the insurance company and its processes, you may receive requests that seem excessive or out-of-line.

Insurance companies may make a wide range of requests for information, but they are subject to certain restrictions. The bottom line: you do not have to provide everything the insurance companies ask for.

As part of the process, you can expect to experience some delays from the insurance company. The law allows delays in certain circumstances. For instance, a delay is permitted when the insurer is waiting for third-party documentation. In some cases, however, an insurance company may delay your claim without reason. At times like that, it is important to know your rights and responsibilities under New York law.

The FAQs on this page answer common questions that medical providers have about the verification process. If you have other questions about your claim, contact The Tadchiev Law Firm, P.C., today.

What Is the Timeline for Insurance Carriers in Their Requests for Additional Verification?

An insurance carrier must send its initial request for additional verification within 30 days after receipt of the claim. If the carrier does not receive a verification response within 30 days after sending its request, the carrier must send a follow-up request within 10 calendar days.

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Are There Any Limits on What Information or Documentation an Insurance Carrier Can Request?

An insurer is entitled to receive all items necessary to verify the claim. However, the additional verification requested should have a rational or reasonable relationship to the specific claim. This means that the verification requested must be relevant to the insurer’s decision on whether to pay or deny the claim.

Similarly, the no-fault regulations require “good reason” for delaying claims for information via verification requests. It has been held, for example, that an insurer did not have a good faith basis to request color photographs of a surgery in order to process a bill.

How Long Does a Medical Provider Have to Respond to Requests for Additional Verification?

A medical provider has 120 calendar days after the carrier’s initial verification request to either submit all requested documentation in its possession or provide reasonable justification for failure to comply with the verification request.

In the event a medical provider either submits a late verification response or fails to provide any response, the provider may still be entitled to payment for the claim if the insurance carrier fails to meet certain requirements. To determine whether you can receive payment for those types of claims, ask a no-fault law firm to review your claim. Contact The Tadchiev Law Firm, P.C., today.

FAQs About the Verification Process

Verification Process

What if the insurance company responds to my no-fault claim by requesting documentation I do not have?

A medical provider only needs to submit verification in its possession. If an insurance carrier requests documentation outside the provider’s possession, then the provider should inform the carrier in a verification response letter that it does not possess the requested documentation. The insurance carrier may be required to issue payment or a denial even if the carrier does not receive all requested verification.

If a provider believes the verification requested is unreasonable or unnecessary, does the provider need to respond to the verification request?

Yes. Even when a provider believes the insurer’s verification requests have no rational relationship to the specific claim, the provider must communicate its objection to the insurer in a proper verification response letter. Failure to provide a verification response objecting to the request will result in a waiver of the defense that the requests were unreasonable.

What if a medical provider only supplies a response to some, but not all, of the requested verification?

If a medical provider only provides a partial verification response, the insurance carrier is required within 30 days to either (1) pay, (2) issue a denial, or (3) send another delay letter acknowledging the material received and requesting the omitted material. An incomplete verification response to requested materials requires action by the insurance company.

What if a medical provider does not understand what is being requested in a particular verification request?

If a verification request is confusing, the provider, using a verification response letter, should ask for clarification of the information sought. The insurance carrier is then obligated to clarify the request once it receives any response to a verification request. If the carrier fails to clarify the verification request, the claim can be viewed as improperly tolled.

Can an insurance carrier delay a claim due to outstanding verification requested more than 30 days after its receipt of the claim?

No. All additional verification must be requested within 30 days of the carrier’s receipt of claim. If a carrier properly delayed a claim by timely requesting additional verification, it cannot delay the claim for other materials outside the initial 30-day period after receipt of the claim.

Can an insurance company delay my claim due to documentation requested from a different provider?

Yes, an insurance company may delay a claim because it requires documentation from a third-party provider. However, the documentation requested from the third-party provider must be relevant to the payment of the claim. Additionally, the insurer must meet a certain timeline in requesting documentation from the third-party provider. Furthermore, the insurer must timely inform you regarding the verification requests sent to the third-party provider. In order to ensure your no-fault claim is properly being delayed by an insurance carrier, contact The Tadchiev Law Firm, P.C.

Get Legal Help with Your No-Fault Claim

If you are dealing with a no-fault claim, contact The Tadchiev Law Firm, P.C., today. Our experienced no-fault attorneys understand the claims process and how to navigate it from start to finish. We will give you the personalized service that you deserve, and we will represent you and your claims as aggressive advocates. No-fault claims can be a hassle, but with The Tadchiev Law Firm, P.C., on your side, they do not have to be.

To learn more about how we can help, contact The Tadchiev Law Firm, P.C., today at (718) 380-1200.