No Need to Submit Bills After Pre-Authorization Claim Denied
Better Smile of Western New York, PLLC and Unitrin Auto & Home Ins. Co.
AAA Case No. 412009027754, Arbitrator Thomas J. McCorry
Amount in Dispute: $120.00, amended to $1273.51
Applicant provider originally claimed only $120.00 for an initial dental consultation of the EIP. Applicant then amended this amount to reflect the amount on a claim form requesting pre-authorization for proposed dental procedures that applicant subsequently submitted to the insurer.
The insurer denied the original bill by way of a formal NF-10 and denied the pre-authorization request by way of a letter, both pursuant to a dental peer review.
Arbitrator McCorry held that the peer reviewing dentist was not persuasive to uphold denials based on lack of medical necessity. However, the insurer further argued that the Applicant never actually submitted bills for the remaining dates of service reflected in the pre-authorization request.
The insurer argued:
“that after exhaustive review of the no fault regulations, case law, and arbitration awards reveal that neither the no- fault regulations nor the interpreting common law make an exception to the requirement to timely submit a bill for the actual service rendered if a request for pre-authorization of dental expenses was previously denied.”
Arbitrator McCorry stated that “the law requiring the continued submissions of future claims after being met with a denial of all such benefits, appears to be changing.”
The arbitrator said that he had originally dismissed the holding in State Farm Ins. Co. v . Domotor, 266 A.D.2nd 219, 697 N.Y.S. 348, holding that “once an insurer repudiates liability… the insured is excused from any obligations under the policy,” as this was not reflected in the Insurance Department’s Regulations or Opinion Letters.
However, the arbitrator stated that the recent case of N.Y. Medical Health PC. v. New York City Transit Authority, 24 Misc.3d 1219 (A) (July 13,2009) upholds the decision in Domotor. Thus, Arbitrator McCorry found that the pre-authorization claim was sufficient submission, that the insurer’s denials were inappropriate, and awarded the full amount allowed by the fee schedule.
This thus provides a rare situation in which, a provider need not officially submit bills pursuant to the procedure set forth in the regulation, yet still received full payment for them. It would have been interesting to see here, if the peer review had been persuasive, whether the insurer’s “unofficial” denial would have been equally as effective as the Applicant’s “unofficial” submission.
Roy Mura
Bethany Mazur
Scott Mancuso
There’s that Domotor decision again. I will not rest until either it is held to be “no longer followed,” superceded by regulation, or the judges and arbitrators are all convinced that because every bill in no-fault is a separate “claim” (per LMK v. State Farm), blanket denials do not relieve claimants from the obligation to submit all future bills.