New York State Seal
STATE OF NEW YORK
INSURANCE DEPARTMENT
25 BEAVER STREET
NEW YORK, NEW YORK 10004

The Office of General Counsel issued the following informal opinion on June 17, 2002, representing the position of the New York State Insurance Department.

RE: Claims Submitted by Physicians

Question Presented:

Does the New York Insurance Law contain a provision permitting a physician to submit a "revised" claim to an HMO for up to 6 years after the date of service?

Conclusion:

No. The New York Insurance Law contains no such provision.

Facts:

Mr. A has asked the Department to send him a copy of "the New York State Insurance statute that states that a doctor may submit a revised claim to an insurance company for up to six years after the date of service." Mr. A states that he is engaged in a research project and that his inquiry relates to a physician/HMO relationship and to situations where the HMO makes a determination of benefits for services rendered during an office visit. Mr. A states that his inquiry does not relate to the New York No-Fault Law or to situations involving motor vehicle accidents.

Analysis:

Article 44 of the New York Public Health Law contains the provisions relating to health maintenance organizations (HMOs). Part 98 of Title 10 of the New York Codes, Rules and Regulations contains the regulations promulgated under Article 44 of the New York Public Health Law. Article 32 of the New York Insurance Law contains the provisions relating to life, accident and health insurance policies and to annuity contracts. There are no provisions in Article 44 of the New York Public Health Law, Part 98 of Title 10 of the New York Codes, Rules and Regulations or Article 32 of the New York Insurance Law mandating the time period for participating providers to submit claims to HMOs. Any such time limitation should be contained in the applicable participating provider contract between the provider and the HMO. The Department therefore cannot provide Mr. A with the material that he has requested.

For further information you may contact Senior Attorney Ethan G. Wolfe at the New York City Office.