N.Y. Comp. Codes R. & Regs. Tit. 11 §§ 65-3.11

Current through Register Vol. 46, No. 51, December 18, 2024

Section 65-3.11 - Direct payments

(a) An insurer shall pay benefits for any element of loss other than death benefits, directly to the applicant or, when appropriate, to the applicant's parent or legal guardian or to any person legally responsible for necessities, or, upon assignment by the applicant or any of the aforementioned persons, shall pay benefits directly to providers of health care services as covered under section 5102 (a)(1) of the Insurance Law, or to the applicant's employer for loss of earnings from work as authorized under section 5102 (a)(2) of the Insurance Law. Death benefits shall be paid to the estate of the eligible injured person.

(b) In order for a health care provider/hospital to receive direct payment from the insurer, the health care provider or hospital must submit to the insurer:

(1) a properly executed authorization to pay benefits as contained on NYS form NF-3, NF-4 or NF-5 or other claim form acceptable to the insurer. Execution of an authorization to pay benefits shall not constitute or operate as a transfer of all rights from the eligible injured person to the provider; or

(2) a properly executed assignment on:

(i) the prescribed verification of treatment by attending physician or other provider of service form (NYS form NF-3); or

(ii) the prescribed verification of hospital treatment form (NYS form NF-4), or the prescribed hospital facility form (NYS form NF-5); or

(iii) the prescribed no-fault assignment of benefits form (NYS form NF-AOB) contained in Appendix 13, infra, or an equivalent form containing nonsubstantive enhancements, but no changes may be made to the assignment language itself.

With respect to health care providers, other than hospitals, the use of revised form NF-3 is applicable to all claims arising from motor vehicle accidents, which occur on and after March 1, 2002. With respect to hospitals, the use of revised forms NF-4 and NF-5 is applicable to all claims arising from motor vehicle accidents, which occur on and after September 1, 2002.

(c) The insurer may request, in writing, the original assignment or authorization to pay benefits form to establish proof of claim in accordance with the procedures contained in subdivision (d) of this section. The insurer must maintain the original form in its claim file.

(d) If an assignment has been furnished an insurer, the assignor or legal representative of the assignor shall not unilaterally revoke the assignment after the services for which the assignment was originally executed were rendered. If the assignment is revoked for services not yet rendered, the assignor or legal representative shall provide written notification to the insurer that the assignee has been notified of the revocation.

(e) The draft or check in payment of benefits shall include information sufficient to identify the element(s) of covered expense(s) being reimbursed, or must be accompanied by an explanation containing such identifying information.

Example:Payment of loss of earnings shall indicate that the payment is for loss of earnings, and shall identify the period of lost time from work being reimbursed and the rate at which reimbursement is being made.

N.Y. Comp. Codes R. & Regs. Tit. 11 §§ 65-3.11