Annual SIU Report

The Annual SIU Report is due by March 15 of each year.

The data required in the current reporting forms must be submitted electronically through a secured environment on the Department of Financial Services' Portal Web Site utilizing an online e-form. Hard copies of the Annual SIU Report will not be accepted. Each filing company must establish a minimum of two Portal accounts (for its Trusted Source and two Approvers - an approver may also be the Trusted Source) and sign up for the FraudsSIU application. Select this link for Portal Sign-up instructions.

Overview and important aspects of Annual SIU Report e-form

The Annual SIU Report should contain data for New York business only and show data reflecting the previous calendar year's activity.
Insurers should file the Annual SIU Report only if the insurer has an approved Fraud Prevention Plan on file with the Department and the insurer meets the 3,000 policies issued (in force) threshold for the following lines of business: Automobile, Workers' Compensation and Accident and Health. For insurers writing group Accident and Health business, insurers must report if 3,000 certificates are in force or membership is 3,000 or more. (60,000 for HMOs). Those insurers that meet this threshold must first file an Annual Fraud Prevention Plan with the Department in accordance with Section 409(a) of the New York Insurance Law.
The due date of the report this year is March 15th. Failure to properly report could result in administrative actions and/or fines.
Filers are not allowed to perform a "partial save" of the data. Once each filer accesses the blank form, the filer must complete all applicable fields and then electronically submit the form. Upon submission the filer will receive a Submission ID. Filers may exit prior to submission but no data will be retained.
Previously filed Annual SIU Reports may be edited and resubmitted which will result in a new Submission ID. Edits will not be permitted after May 1.
Do not include data from uninsured (ASO) business in the columns 1a - 2b of the grid. Separate questions below the grid pertain to ASO financial data. Include ASO business in the remaining columns (3a - 6b) of the grid.
Groups that have both Property and Casualty (P&C) and Accident and Health (A&H) companies and meet the Section 409 threshold must file separate Annual SIU Reports for the P&C and A&H companies.
Each insurer's Annual SIU Report submission must be electronically approved by the SIU Manager and by an Executive Officer. See “Directions for sign off of the e-form by the SIU Manager and Executive” below.
Each insurer must have a minimum of 2 accounts to complete, submit and signoff on the e-form. Each insurer must have a Trusted Source, a Reviewer - SIU Manager and a Reviewer - Executive. A reviewer may also be a Trusted Source. Insurers may create an additional "Submitter" account.
Once the Trusted Source account is created, the Trusted Source should approve additional users.
At sign-up for account creation, each individual must identify a "Lead Company." All individuals (Trusted Source, Reviewer and Submitter) from a given group must use the same company (insurer name, NAIC Number) as the Lead Company in order to be able to access the e-submission.
The "Lead Company" is the insurer, selected by the filer, that serves as the common link among all users accessing the same submission. The Lead Company also provides the submitter of the Annual SIU Report with the option to include any and all affiliates in the filing via a dropdown list. If an insurer has no affiliates, then that insurer is the Lead Company.
Prior to the input of data to the Annual SIU Report, each filer must select the company or companies to be included in the filing. Companies that are members of a holding company or group may file on behalf of the entire group via one filing or may make multiple filings. (Except, as noted above, A&H and P&C companies cannot be combined on a single form.) If a group wants to make multiple filings, then multiple Lead Companies must be selected. See Directions below for adding additional insurers to an existing account.
After the report form has been completed, the form must be submitted to the Department and then signed off by the SIU Manager and, as stated in Regulation 95 Section86.6(d), "by an executive officer of the insurer responsible for the operations of the Special Investigations Unit." The SIU Manager and the Executive Officer must log in to the Annual SIU Report via the portal to access the sign-off feature of the application; therefore both the SIU Manager and the Executive Officer must create portal accounts. Please note, as stated above, the SIU Manager and the Executive Officer must identify the exact same Lead Company at sign up.

Select this link for Electronic Submission - Step-by-Step Instructions

Directions for accessing and inputting data to the e-form

After logging into the Department’s Portal, the Portal Home Page will appear.

Select FraudsSIU under My Applications

Then click on "Actions" and then "View"

Then select your Lead Company from under "Available Company Groups".

Then select the affiliates to be included in the filing. Then click on "Next Step" and the Annual SIU Report form will appear.

All data reported are to be broken down by the following lines of business:

P&C	A&H
Non-Commercial motor vehicle	Medical, Hospital, Dental, Rx
Commercial motor vehicle	Disability (LTD, STD)
Workers’ Compensation	Stop-loss
Accident and health	Accident and other health insurance

Enter whole numbers (not in thousands)

1a.& 1b. - New York policy count, Premiums written

1a. & 1b.-Indicate policy count or individuals covered if policies are written on a group basis, and the corresponding premiums written. Assigned Risk should be included. Do not include ASO business.

2a.& 2b.- Number of claims processed, Dollar amount of claims processed

2a. - All claims that have been received and that are in the various stages of review for ultimate payment or denial. (This includes claims that have not been entered into the company claims system). Do not include ASO business.
2b. - Total dollar value of claims incurred (including incurred but not paid) during the calendar year being reported. Do not include ASO business.

Include ASO business in columns 3a - 6b

3a.& 3b. - Number of suspicious claims detected, Dollar amount of suspicious claims detected

3a. - Claims containing information that leads the reviewer to question the integrity/credibility of the claim or that provides information indicating a pattern or trend of questionable organized activity. Report the number of claims referred to the SIU, from the claims department within the calendar year.
3b. - Report the corresponding dollar amount of the claims.

3c.& 3d. - Number of claims reviewed by SIU, Number of referrals reviewed by SIU

3c. - Report the number of suspicious claims detected by the SIU resulting from audit or software analysis. These claims have not been detected via the claims payment process.
3d. - Total number of referrals reviewed by SIU. Column 3d could be a total of 3a +3c however referrals may have come from other sources so 3d could be larger that the total of 3a +3c.

3e. Number of cases opened by SIU

3e. - Total number of referrals, claims (cases) opened for investigation during the calendar year.

3f. Number of cases closed by SIU

3f. - Total number of investigated cases closed during the calendar year being reported.

4a.& 4b. Dollar value of savings. Dollar value of restitution and recoveries.

4a. - Monies not paid due to investigation of suspicious claims submitted during the calendar.
4b. - Monies collected/recovered from all sources including from court disposition during the calendar year.

4c.& 4d. Number of investigated claims closed and not paid. Number of claims closed and partially paid

4c. - Number of claims not paid as a direct result of SIU investigations during the calendar year.
4d. - Number of claims that resulted in partial payments as a result of SIU investigations.

5. Number of IFBs reported to the NY Frauds Bureau

5. - The number of reports of suspected fraudulent transactions that were sent to the Insurance Frauds Bureau during the calendar year.

6a..& 6b. Total cost of SIU. Number of SIU investigators (This section should be broken down by Insurer (I) or Contractor (C)). Report the total amount in the bottom row only.

6a. - For national and regional SIU units, report amounts allocated to New York. Include salaries, rent and other expenses.
6b. - Report the number of New York investigators on an allocated FTE basis. FTE = one full time equivalent investigator. For multi-state SIUs, allocate the New York FTEs using methodology in accordance with the New York Insurance Law and Department regulations.

Select this link for Electronic Submission - Step-by-Step Instructions

Questions

The following questions pertain to the SIU operations as a whole.

How many referrals were made to law enforcement agencies other than the New York State Department of Financial Services' Insurance Frauds Bureau?

(The number of "IFBs" reported to the Insurance Frauds Bureau is contained in section 5d. of this report.)

How many civil actions involving suspect transactions were initiated during the reporting year?

This includes all lawsuits to recover claims payments or premium amounts on investigated cases. Recoveries made without initiation of a lawsuit should be reported in 4a. & b.

What were the total expenses (allocated and direct) of the public awareness program?

Report the allocated and direct expenses incurred for the public awareness program. (New York State only)

What is the dollar amount of claims adjudicated for self funded groups?

Include claims paid during the calendar year being reported, regardless of incurred date, on administrative services only business.

How many claims were paid for self funded groups during the reporting year?

Report the number of claims paid during the calendar year, regardless of incurred date, on administrative services only business.

How many IFBs were reported to NYS Frauds on all other lines of business not included above?

Input the number of reports of insurance fraud filed for lines of business not shown above in the grid section of the Report, such as Life, Homeowners, Mortgage Guaranty etc.

Where is the SIU located (city, state)?

If employees of SIU are in different locations, list the location where the majority of personnel are located.

What was the percentage of investigators’ time actually spent physically in New York working on New York cases?

As a percentage of the number reported in column 6b, indicate the amount of investigators' time worked in New York State on New York State cases. If all investigators are located out of state but work on New York cases, the percentage would be 0%. If the investigators are located in New York but spend half of their time working on out of state cases the percentage would be 50%. Enter the total percentage as a whole number followed by the percent symbol; for example: "95%" or "8%". If the insurer's response is a percentage arrived by allocation and is less than one; enter a decimal point before the number(s) and then enter the percent symbol; for example: ".50%" or ".3%".

Is the insurer submitting an amendment to the Fraud Prevention Plan?

New Fraud Plans, amendments and information filings may be sent to insurerfraudpreventionplan@dfs.ny.gov. Once a Fraud Prevention Plan has been approved by the Insurance Frauds Bureau it is not necessary to resubmit a complete Fraud Prevention Plan every year. The following changes must be approved by the Insurance Frauds Bureau:

Changes affecting operations of the SIU
Remedies to deficiencies reported to or observed by the Insurance Department and/or the insurance company.

Directions for sign off of the e-form by the SIU Manager and Executive

Select this link for Electronic Submission & Sign off - Step-by-Step Instructions

Both the SIU Manager and an Executive Officer must sign off on the form.

After the form has been completed, the insurer may submit the form. Upon submission of the form, the insurer will receive a “Submission ID.” This ID number will allow the insurer to access the form after submission. (If the Submission ID is not retained, the filing can be retrieved via query.)

The following is the process for approval of the Annual SIU Report.

After the e-form is submitted, the submitter will receive a "Submission ID", which can be used to access the form. The Reviewer - SIU Manager should receive an email that the form has been submitted and is ready for approval. Once the Reviewer - SIU Manager approves the filing, the Reviewer - Executive will get an email that the form is ready for approval.
The SIU Manager and Executive responsible for the SIU must each sign in to the portal. After signing into the portal:
- Select the FraudsSIU under My Applications.
- Select "Actions" and then "View".
- Select the Tab labeled Review/Approve Submissions
- A screen will appear which requires the individual to enter information such as the submission ID or company name (drop down menu) so that the form can be retrieved. Then select the Search button.
- A list of submissions will appear.
- The reviewers should select the appropriate submission to review and then approve it by clicking on the "Approve" box.

Click SIU Annual Report to go to Portal Login.