New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 65 - Regulations Implementing The Comprehensive Motor Vehicle Insurance Reparations Act › Subpart 65-3 - Claims For Personal Injury Protection Benefits › Section 65-3.16 - Measurement of no-fault benefits

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Medical expenses.
(1) Payment for medical expenses shall be in
					 accordance with fee schedules promulgated under section 5108  of the Insurance Law and contained in
					 Part 68 of this Title (Regulation 83).
(2) Where an applicant receives treatment
					 from a health maintenance organization, an Insurance Law article 43
					 corporation, a veterans administration hospital or provider, or any other
					 provider which does not render specific charges for services, or where any such
					 charges are indeterminate, the applicant shall be entitled to payment of
					 benefits equal to the value for equivalent services rendered by a provider as
					 limited by section 5108  of the Insurance Law and Part 68 of
					 this Title (Regulation 83).
(3)
					 Pursuant to section 5102 (a)(1)  of the
					 Insurance Law, an insurer shall not be liable for the payment of medical and
					 other benefits enumerated in section 5102 (a)(1)  of the
					 Insurance Law if, during a period of one year from the date of the accident, no
					 such expenses have been incurred by the applicant.
(4) The term nursing, as used in section 5102 (a)(1)(i)  of the
					 Insurance Law, shall include but not be limited to all necessary services
					 rendered to the eligible injured person by a licensed practical
					 nurse.
(5) If the applicant's
					 injuries warrant occupational therapy or rehabilitation based on an attending
					 physician's recommendation, or if the injuries have rendered the applicant
					 unable to resume the applicant's occupation, the insurer shall inform the
					 applicant of the coverage for occupational therapy or rehabilitation required
					 by section 5102 (a)(1)(ii)  of the
					 Insurance Law, and the insurer shall assist the applicant in obtaining such
					 occupational therapy and rehabilitation.
(6) The term any other professional health
					 services, as used in section 5102 (a)(1)(iv)  of the
					 Insurance Law, this Part and approved endorsements, shall be limited to those
					 services that are required or would be required to be licensed by the State of
					 New York if performed within the State of New York. Such professional health
					 services should be necessary for the treatment of the injuries sustained and
					 within the lawful scope of the licensee's practice. Charges for the services
					 shall be covered pursuant to schedules promulgated under section 5108  of the Insurance Law and Part 68 of
					 this Title (Regulation 83). The services need not be initiated through referral
					 by a treating or practicing physician.
(7) The scope of the term religious methods
					 of healing recognized by the laws of this State, as used in section 5102 (a)(1)(iii)  of the
					 Insurance Law, this Part and approved endorsements, is a method recognized
					 under article 131 of the Education Law. Charges for such services shall be
					 covered pursuant to schedules promulgated under section 5108  of the Insurance Law.
(8) Services rendered to the eligible injured
					 person by a certified or licensed home health care agency shall be considered a
					 medical expense payable under section 5102 (a)(1)  of the
					 Insurance Law.
(9) Pursuant to
					 section 5102 (b)(2)  of the
					 Insurance Law, when the applicant is entitled to workers' compensation benefits
					 due to the same accident, the workers' compensation carrier shall be the sole
					 source of reimbursement for medical expenses.
(10) If a provider of health service requires
					 proof of the applicant's ability to pay for the services to be rendered as a
					 result of the accident, the insurer shall provide the applicant or the provider
					 (if the applicant is entitled to benefits) with a letter stating that the
					 applicant has coverage under its policy and that the necessary medical expenses
					 incurred as a result of the accident are covered expenses subject to the policy
					 limits and conditions and applicable fee schedules.
(11) Within 30 calendar days of a submission
					 by a dentist or plastic surgeon of a proposal for a course of treatment and
					 charges, an insurer shall review such proposal and notify the provider as to
					 whether or not payment will be made in accordance with the proposal. The
					 foregoing shall apply to nonemergency situations and when the course of
					 treatment is expected to involve covered expenses of $250 or more.
(12) A provider of health care services is
					 not eligible for reimbursement under section 5102 (a)(1)  of the
					 Insurance Law if the provider fails to meet any applicable New York State or
					 local licensing requirement necessary to perform such service in New York or
					 meet any applicable licensing requirement necessary to perform such service in
					 any other state in which such service is performed.