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Tip 7

Best Practices for Hospitals: Verification Requests and the 120-Day Rule

Erin S. Stamper and Bruce M. Klein

Generally, all verification requests must be answered, either in whole or in part, within 120 days of the date of the initial request. Two or more requests may be received, and each will contain language advising the hospital of the 120-day deadline for providing the requested documentation/information. Note, however, that the 120-Day Rule does not apply to all verification requests. Specifically, the 120-Day Rule does not apply to requests for prescribed forms (e.g. AOBs, NF-2s, etc.).[1] As such, a denial based on the hospital’s the failure to provide a requested form within 120 days of the date of the initial request, is defective and should be arbitrated.

When responding to verification requests, the hospital should be guided by the following precepts:

  • Provide only the documentation/information of which the hospital is in possession, including all test results, licensure information, etc.;
  • If the hospital is not in possession of the requested information/documentation, it should indicate same and provide the no-fault insurer with any information that it may have regarding the identity of the party that may be in possession of said materials;
  • If the hospital is not going to provide an item being requested in verification, it must advise the no-fault insurer that the item will not be produced and its reason for not providing same (e.g., Please be advised that the hospital will not be providing toxicology reports because no such testing was performed);
  • At the close of its verification response, the hospital should demand that its outstanding claim be processed within thirty days;
  • In the patient’s Account Notes, hospital staff should indicate the date that a verification response is sent, to whom it is sent, and how it is sent (e.g., On January 1, 2018, faxed requested verification to Karen Jenson of Allstate at 800-123-4567);
  • Retain a complete copy of the verification response with proof of mailing (i.e. the fax confirmation) in the patient’s file.

Depending on the nature of the medical services rendered, be they emergent or non-emergent care services, the hospital can expect to receive different verification requests. The hospital’s obligation to provide certain information/documentation depends on the nature of the services rendered.

Emergent Care

Upon request, the hospital is generally obligated to supply the no-fault insurer with the following prescribed forms:

  1. UB-04: to be provided to no-fault insurer within 30 days of date that treatment was rendered. The UB-04 constitutes both notice and proof of claim;
  2. NYS Form AOB: to be provided to no-fault insurer upon request. However, any form of authorization or assignment (even if not on the prescribed form) is accepted for emergent care;
  3. NF-5: to be provided to no-fault insurer upon request.

Note: The no-fault insurer may not utilize a verification request for an NF-2 to delay payment for the hospital’s claim for emergency services. Rather, if the no-fault insurer deems the UB-04 insufficient to process the claim, it may request that the hospital provide a form NF-5.

Often, the following documents are also sought to verify emergent care services, with or without an inpatient admission:

  1. Medical records – with appropriate coding;
  2. Diagnostic results;
  3. Letter addressing either the medical necessity of the services rendered or the causal relationship between the motor vehicle accident and the medical services rendered.

Non-Emergent Care

The following prescribed forms may be requested for non-emergent care, including clinic and inpatient admissions:

  1. Executed AOB- if not asked for in verification, should be considered waived.
  2. NF-4 –Hospital Treatment Form
  3. NF-3 –Physician Treatment Form, sometimes sent in conjunction with or in lieu of NF-4.
  4. NF-2—although the hospital is not obligated to submit this form, if notice of the accident is not received by the no-fault insurer within thirty days of the accident, coverage may not exist.
  5. Other NF forms that are required to be completed by an insured person, not by the hospital.

The following documents are often requested for clinic and elective medical care, like surgery. With respect to these verification requests, the hospital has an advantage if a significant number of its treating physicians are also employees of the hospital system and, as such, treatment records may be easily obtained.

  1. Initial Narrative Reports;
  2. Office Notes;
  3. Diagnostic Records, which may include a request for a CD containing the MRI images;
  4. Operative reports;
  5. Letter addressing either the medical necessity of the services rendered or the causal relationship between the motor vehicle accident and the medical services rendered.

As previously stated, all verification requests should be answered, either in whole or in part, within 120 days. The response to verification must be specific. The verification response must identify the verification request to which it is responding, by date, and should itemize the documentation/information being sent. If a requested item is unavailable, the hospital must advise the no-fault insurer that it is unavailable. For example:

Example 1:

Allow this letter to serve a response to Allstate’s verification request, dated January 1, 2018, for date of service December 1, 2017, billed amount $1,200.00. Enclosed please find the following requested materials:

  1. Pre-operative report
  2. Operative report.

The following requested items are not in the hospital’s possession or control but may be obtained by contacting XYZ Radiology:

  1. Pre-Operative MRI Films

As the hospital has provided all the requested documentation within its custody and control, please process this claim within 30 days of receipt of this correspondence.

Example 2:

Allow this letter to serve a response to Allstate’s verification request, dated January 1, 2018, for DOS December 1, 2017, billed amount $1,200.00. Please be advised that there exists no letter of medical necessary for the surgery performed on December 1, 2017. As the Regulations do not require the hospital to create a record to satisfy verification, enclosed please find the following records that shall serve to address the medical necessity of the services rendered: (a) office notes, (b) MRI report, and (c) operative records. Please process the hospital’s claim for payment.

Example 3:

Dear Ms. Smith, Allstate Rep.:

DOS: 12/01/2017, Claim Amt. ­­­­­$101.00;

DOS: 12/06/2017, Claim Amt. ­­­­­$1,200.00;

The Hospital writes in response to the two identical verification requests identified above. Attached please find all medical records that are in the possession of the hospital and its employed physicians. The Hospital is not in possession of an initial evaluation of the patient by Dr. Clarke. Furthermore, under the Regulations, the Hospital is under no obligation to create and provide a separate letter addressing the causal relationship between the motor vehicle accident and the services rendered. As such, no such letter shall be forthcoming. Rather, the enclosed records shall serve to address the medical necessity of the treatment rendered and the causal relation of said treatment to the accident.At this time, the Hospital requests that its claim be processed.

Example 4:

Re: GEICO’s Verification Requested, dated 1-15-18

DOS: 12-1-2017

Billed Amt: $6,500.00

Please find attached operative report of December 1, 2017. There is no requirement for the creation of a separate letter in support of the causal relationship of the injury to the accident. As such, no such letter shall be forthcoming. The Hospital has now answered all outstanding verification. Please send the payment due within 30 days.

Example 5:

Re: GEICO’s Verification Requested, dated 1-15-2018

DOS: 12-1-2017

Billed Amt: $101.00

The requested statements are not under the control of the Hospital and, therefore, cannot be provided. Therefore, please process the instant bill within thirty days of receipt of this correspondence. If verification requests for statements were sent directly to the patient, please provide the Hospital with copies of same.

Conclusion

Both to increase its likelihood of receiving voluntary payment and to ensure its compliance with the 120-Day Rule, there are a few guiding principles that the hospital should follow when handling verification requests. First, all verification requests should be answered, either in whole or in part, within 120 days of the date of the initial verification request. Second, a response to verification must be specific, identifying the verification request to which it responds, by date, and itemizing the documentation/information being sent. Third, if a requested item is unavailable, the hospital must advise the no-fault insurer that said item is unavailable and will not be provided. Fourth, at the close of its verification response, the hospital should demand that its claim for payment be processed within thirty days. Fifth, the hospital should retain a copy of the complete verification response with proof of mailing in the patient’s file. Sixth, in the patient’s Account Notes, hospital staff should indicate the date that a verification response is sent, to whom it is sent, and how it is sent (e.g. fax, USPS, etc.).

To the extent that the hospital receives verification requests that appear to be overreaching or improper, said requests should be forwarded to Russell Friedman & Associates for review. Similarly, to the extent that the hospital receives a denial stemming from a defective verification request, same should also be referred to the Firm for review and arbitration.

Within the year, the Firm expects further clarification from the Regulator on the 120-Day Rule. Upon the Firm’s receipt of same, additional advices will be forthcoming.


[1] 11 N.Y.C.R.R. §65-3.5(o), which sets for the 120-Day Rule, specifically states “[t]his subdivision shall not apply to a prescribed for (NF-Form) as set forth in Appendix 13 of this Title, medical examination request, or examination under oath request.”

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What Sets Us Apart From Our Competitors?

  • Fighting for Compensation

    We use negotiation, arbitration, or litigation to ensure medical providers are fairly compensated for their services.

  • Experienced Attorneys

    We have a team of trusted and respected attorneys to ensure your case is matched with the best attorney possible.

  • Client-Focused Approach

    We’re a client-centered, results-oriented firm. When you work with us, you can have confidence we’ll put your best interests at the forefront of your case – it’s that simple.

  • We'll Fly to You

    We fly throughout New England to meet with medical providers and hospitals to help them with collection, consulting and compliance.

  • Creative & Innovative Solutions

    No two cases are the same, and their solutions shouldn’t be either. Our attorneys provide creative points of view to yield exemplary results.

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