Instructions on Submission of the Annual SIU Report
- Instructions for SIU Report Submitter
for SIU Report Approvers: SIU Manager and Company Executive
The due date for this report is March 15th. The Annual SIU Report should contain data for New York business only.
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.
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. See Directions for sign off of the e-form by the SIU Manager and Executive, below.
IMPORTANT: At sign-up for account creation, each individual must identify a "lead company." All individuals from a given company must use the same company (insurer name, NAIC No.) as the lead company in order to be able to access the submission.
Groups that have both P&C and A&H companies and meet the Section 409 threshold must file separate Annual SIU Reports for the P&C and A&H companies.
Each company that is a member of a group must identify all insurers included in the filing.
After logging into the DFS Portal, select My
Applications, then select Frauds SIU-Actions-View (See below):
On Frauds SIU Form, select the appropriate form type: click the Submit AH Form Tab for Accident & Health Insurers or the Submit PC Form Tab for Property/Casualty Insurers (see below):
Your Company/Group(s) should be displayed on the screen (these are the Company(s)/Group(s) you requested during Sign-up). A list of affiliated companies will appear once you click on a group name. Select all companies to be included in the current report (see below):
The first of 3 Annual SIU Report forms will appear. See below for the data requirements of the Annual Report.
Instructions on completion of the form grid:
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 paid
- 2a. All claims that have been received and that are in the various stages of review for ultimate payment or denial. (These claims have been entered into the company claims system). Do not include ASO business.
- 2b. Total value of claims 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 indicators of fraud or that provide information indicating a pattern or trend of questionable organized activity.
- 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 claims reviewed by the SIU resulting from audit, software analysis or other means of identifying suspicious claims other than 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 than the total of 3a and 3c.
3e. Number of cases opened by SIU
- 3e. Number of referrals or claims that have been assessed by the SIU and subsequently opened for investigation during the calendar year.
3f. Number of cases closed by SIU
- 3f. Number of investigated cases closed during the calendar year.
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 year.
- 4b. Monies collected/recovered from all sources including from court disposition during the calendar year being reported.
4c. & 4d. Number of investigated claims closed and not paid. Number of claims closed and partially paid.
- 4c. Claims not paid as a direct result of SIU investigations during the calendar year being reported.
- 4d. Number of claims that resulted in partial payments as a result of SIU investigations.
5. Number of referrals reported to the NYSDFS, Insurance Frauds Bureau.
6a. & 6b. Total cost of SIU. Number of SIU investigators (These columns should be broken down by Insurer (I) and Contractor (C)). Report the total amount only in 6a and 6b.
- 6a. & 6b. For national and regional SIU units, New York allocations must be determined using FTE activity for New York cases. FTE = one full time equivalent investigator.
Please respond to the additional nine questions:
1. How many referrals were made to law enforcement agencies other than the New York State Department of Financial Services?
The number of IFBs reported to the NYSDFS is contained in section 5.d. of this report.
2. How many civil actions involving suspect transactions were initiated during the reporting year?
Include the number of lawsuits initiated to recover amounts paid on investigated cases.
3. What were the total expenses (allocated and direct) of the public awareness program?/
Report direct and allocated expenses incurred for the public awareness program.
4. What is the dollar amount of claims adjudicated for self-funded groups?
Report the dollar amount of claims incurred for self-funded groups, include IBNR.
5. How many claims were paid for self-funded groups?
Report the number of claims incurred during the calendar year, include IBNR.
6. How many IFBs were reported to the NYSDFS on all other lines of business not included above?
Provide the number of IFBs reported to NYSDFS on lines of business not shown above in the grid section of this Report, such as life, homeowners, property etc.
7. Where is the SIU located?
Provide the city and state of the primary location of the SIU.
8. What was the percentage of investigators’ time actually spent physically in New York work on New York cases?
As a percentage of the number reported I column 6b, indicate the amount of investigators’ time worked in New York State on New York 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 at by allocation and is less that 1%, enter a decimal point before the number(s) and then enter the percent symbol; for example.50% or.03%.
9. Is the insurer submitting an amendment to the Fraud Prevention Plan?
New and revised fraud prevention plans, amendments and informational filings should be submitted to the NYSDFS Insurance Frauds Bureau via the portal using the application titled Frauds Prevention Plans. Access and instructions to Frauds Prevention Plans can be found on the Department’s website. The following webpage contains a link to the portal and to the instructions for filing a new fraud prevention plan: http://www.dfs.ny.gov/insurance/fdidx_in.htm.
After all 3 input forms have been completed and reviewed, click "Complete Submission" button to transmit the report. The e-Submission ID will now be displayed (see screen below). Please record this Submission number for future reference.
A Reviewer SIU Manager and Reviewer Executive 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 SIU Manager and Executive responsible for the SIU must sign into the portal, select My Applications, then select Frauds SIU-Actions-Review Approve Submission (See below):
Enter any of the following information the Submission ID, Submission Year, Lead Company. Click Search (see below):
A list of submissions will appear. The reviewer should click on the appropriate submission to review it and then to approve it.