New York State seal

August 1, 1979

SUBJECT: INSURANCE

WITHDRAWN

Circular Letter NO. 23

AUGUST 1, 1979

TO: ALL ACCIDENT AND HEALTH INSURERS, EXCLUDING ARTICLE IX-C CORPORATIONS, LICENSED IN NEW YORK STATE

RE: STANDARD CLAIM FORMS FOR ACCIDENT AND HEALTH INSURANCE

Department Regulation 88, effective January 1, 1979, established for commercial insurance companies standard claim forms for the services of physicians, dentists and hospitals to be used for all claims arising out of insurance authorized by Section 46.3 of the New York Insurance Law.

This is to remind commercial insurers that, on and after September 1, 1979, no commercial insurer may require any physician, dentist or insured to complete claim forms differing from the medical and dental standard claim forms established by the Superintendent in Regulation 88. Additionally, on and after November 1, 1979, no commercial insurer may require any hospital to complete claim forms differing from the inpatient hospital claim form established by the Superintendent in such Regulation.

A number of questions have arisen concerning the use of the reverse side of the standard claim form for physician services. The Department has no objection to insurance company claim instructions and employer information appearing on the reverse side of the standard claim form. The use of the reverse side of the form for these purposes should eliminate the need for separate inquiry statements with resulting economy to the insurer and policy-holder.

No alteration, however, may be made to the format of the face page of the standard claim form.

Very truly yours,

[SIGNATURE]

ALBERT B. LEWIS

Superintendent of Insurance