The State Insurance Department (SID) has issued a regulation that imposes additional obligations on health insurers who attempt to deny a claim or take back payment from a physician alleging another insurer is financially responsible. The regulation applies to those situations where more than one New York-licensed health insurance company insures a patient and is effective for claims submitted after July 15, 2009

There are three major components to the regulation.

First, it sets forth a general rule that grants a physician or other health care provider an additional 60-day window to submit a claim to a financially responsible insurer following the receipt of a notice of a benefit determination from the insurer to whom the claim was originally submitted.

Second, it sets forth rules to assure that health insurers denying payment for claims alleging other primary coverage must provide the physician with adequate information regarding the alleged other coverage. If the physician after reasonable efforts is unable to confirm other coverage, the health insurer initially denying coverage becomes liable.

Third, it would require insurers that allege on a post-payment basis that other primary coverage exists to postpone for at least 120 days recouping the payment.

Additionally, the insurer must provide the physician with adequate information regarding the alleged other coverage. If the physician, after reasonable efforts, is unable to confirm other coverage; the health insurer alleging other coverage remains responsible for the claim.

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