OGC Opinion No. 09-07-05: Health Insurance, Time Limit on Claim Submission | Department of Financial Services

ogc op. No. 09-07-05

The Office of the Attorney General issued the following opinion on July 22, 2009 representing the position of the New York State Department of Insurance.

re: health insurance, time limit for filing claims

submitted questions:

1. Is there a minimum amount of time an insurer, including an HMO, must allow for claims to be submitted by a participating provider?

Reading: How long does a provider have to submit a claim to insurance

2. If there is no time limit for filing a claim in the contract between the participating provider and the insurer, how long does a participating provider have to file a claim with the insurer?

3. If an insurer, including an HMO, denies a claim from a participating health care provider as obsolete, would the amount that would otherwise be payable to the provider be payable to the state under new york abandoned property law?

conclusions:

1. No. There is no minimum amount of time that an insurer, including an hmo, must allow for the submission of claims by a participating provider.

2. If the contract between the provider and the insurer says nothing about what would constitute a timely claim, then the insurer must provide for filing a claim within a reasonable time.

3. Interpretations of the abandoned property law are within the purview of the New York State Department of Audit and Control, not the New York State Department of Insurance. consequently, the insurance department will not opine on this matter.

facts:

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the applicant’s law firm represents various health care providers, including institutions and individual practitioners, and that, as part of the legal representation, the firm is called upon to review participating provider contracts between its clients and insurers, including hmos. the researcher further reports that:

The researcher asks if the law prescribes a minimum amount of time for which an insurer must allow claims to be submitted by a provider.

The questioner further reports their understanding that a health care provider has a legal obligation under the abandoned property law to remit credit balances to the state under certain circumstances, and asks if the understanding is correct.

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analysis:

me. claim filing time

Applicant asks if there is a minimum amount of time within which an insurer must allow a claim to be submitted by a participating health care provider.

The analysis is limited to the interpretation of the new york insurance law insofar as it regulates accident and health insurance, medical expenses insurance and HMO subscription contracts. This opinion is not intended to express views on the time limits imposed by any statute, state or federal, regarding such matters as Medicare or no-fault auto insurance. nor does it address any legal requirements imposed on non-participating health care providers or members.

n.y. in s. law §§ 3217-b and 4325 (mckinney supp. 2009) and n.y. pub. Health Law § 4406-C (McKinney Supp. 2009) establishes provisions that regulate various aspects of the relationship between insurers and participating health care providers. But neither insurance law nor public health law establishes a minimum amount of time within which an insurer, including an HMO, must allow a claim to be submitted by a participating health care provider. In addition, the Department of Insurance understands from discussions with the New York State Department of Health that, when reviewing a contract between an HMO and a provider, the Department of Health does not require that the contract state a minimum period of time within which an insurer must allow for the filing of a claim. Neither the insurance department nor the health department reviews contracts between a non-hmo insurer and a provider.

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Accordingly, there is no minimum amount of time that an insurer, including an hmo, must allow for the submission of claims by a participating provider.

ii. time for filing claims when the contract is silent

Next, the investigator asks how long a provider has to file a claim when the contract between the provider and the insurer does not mention the issue. when the contract does not say anything about it, the insurer must allow a reasonable period for the presentation of the claim by the provider. the insurance department has not established by regulation the duration of said period of time.

iii. abandoned property

Lastly, the investigator asks whether an amount that would otherwise be payable to a participating health care provider would be payable to the state as abandoned property if an insurer, including an hmo, denied a participating provider’s claim as obsolete. specifically, you report that you believe that n.y. Abandoned Property Law § 1316 (Mckinney Supp. 2009) applies to third-party payer credit balances held by entities, including health care providers, and see if there are any reciprocal requirements applicable to health insurers.

Interpretations of the abandoned property law are within the purview of the New York State Department of Audit and Control. accordingly, any queries regarding the law of abandoned property should be directed to that agency.

for more information, you may contact lead attorney alan rachlin in the new york city office.

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