PRIMA FACIA – BY REPORT CODES

PRIMA FACIA – BY REPORT CODES

PAVLOVA, v.ALLSTATE INSURANCE COMPANY, 2016 WL 1588839

The Civil Court in this case appears to expand on what constitutes a Plaintiff’s prima facia and what Vivienne Etienne requires.  Although this is a civil court case, the court said as follows:

With regard to the remaining code 20999, defendant argues that plaintiff has not satisfied its prima facie burden because plaintiff’s claim is incomplete. Specifically, defendant contends plaintiff did not provide sufficient information in support of the amount it charged for the services it designated with code 20999 of the Fee Schedule. Instead of having a relative value associated with the service, code 20999 is designated “By Report,” abbreviated “BR.” The Fee Schedule states that, in order to determine the appropriate monetary value of services designated “BR,” plaintiff must provide certain information.

Information concerning the nature, extent, and need for the procedure or service, time, skill and equipment necessary, etc., is to be furnished using all of the following:

  1. A) Diagnosis (postoperative), pertinent history and physical findings.
  2. B) Size, location, and number of lesions or procedures where appropriate.
  3. C) A complete description of the major medical procedure and the supplementary procedures.
  4. D) When possible, list the closest similar procedure by code and relative value unit. The “BR” relative value unit shall be consistent in relativity with the other relative value units in the schedule.
  5. E) Estimated follow up period, if not listed.
  6. F) Operative time.

(see Fee Schedule, Section 4 Surgery, at 4, Surgical Ground Rule No. 10 [June 1, 2012 ed.] ). In its papers, plaintiff makes no showing that it provided this information.

Neither plaintiff nor defendant provides any case law to support or refute defendant’s argument that this information is part of plaintiff’s prima facie burden, and this Court has found no governing precedent. Thus, this issue appears to be a matter of first impression in this jurisdiction.

This Court views “By Report” information as, by definition, part of the proof of plaintiff’s “completed claim form” (see Viviane Etienne, 25 NY3d at 507), and thus part of plaintiff’s prima facie burden. The Fee Schedule, which has been adopted into New York’s no-fault regulations (see 11 NYCRR § 68.1[a] ), places an affirmative duty on the medical provider to submit this information to justify its billing. By omitting this information, plaintiff deprived defendant of sufficient notice of the claim. Without sufficient notice, defendant should not be expected to evaluate and pay the claim. Consequently, plaintiff did not establish its prima facie case for services related to code 20999.

Hard to know where the Court was coming from without looking at the underlying papers and what the Plaintiffs medical records looked like.

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