Under New York’s 45-day timely payment rule, claims administrators must pay or object to a medical bill within 45 days, or they lose the right to dispute the charge.
45-Day Timely Payment Rule
Within 45 days after a bill is submitted, the claims administrator must do one of the following:
- Pay the bill, or
- Object to the bill and notify the provider of the reasons for non-payment.
Untimely Objections Barred
If the bill is not paid or objected to within 45 days, the claims administrator must pay the bill in full up to the maximum amount established in the applicable fee schedule. The New York Workers' Compensation Board (NY WCB) will not uphold late objections.
New York |
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Rule |
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Section |
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Subsection Text |
325-1.25 (c) (1) The employer or insurance carrier (or third-party administrator), within 45 days after the bill has been submitted shall pay the bill or shall notify the physician, occupational or physical therapist, podiatrist, chiropractor, psychologist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital, or other provider of medical care, and the board in the format prescribed by the chair (which may be electronic) for such purpose that the bill is not being paid and the reasons for non-payment. If the employer or insurance carrier (or third-party administrator) objects to payment of all or part of the bill for reasons concerning its legal liability for payment, the legal objections shall be placed on the chair prescribed form for such purpose and submitted to the physician, occupational or physical therapist, podiatrist, chiropractor, psychologist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital, or other provider of medical care, and the board. If the employer or insurance carrier (or third-party administrator) objects to payment of all or part of the bill for reasons concerning the value of the treatment performed or the amount billed, the valuation objections shall be placed on the chair prescribed form for that purpose and submitted to the physician, occupational or physical therapist, podiatrist, chiropractor, psychologist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital, or other provider of medical care, and the board, except if the only objection is that the amount billed for the particular Current Procedural Terminology (CPT) code is in excess of the appropriate fee schedule for the region where the services were provided then the insurance carrier or employer (or third-party administrator) may file its explanation of benefits form. If the employer or insurance carrier (or third-party administrator) objects to payment of all or part of the bill for one or more of the medical treatment guidelines objections set forth in paragraph (7) of this subdivision, the objections shall be placed in the format prescribed by the chair (which may be electronic), along with the basis for the objection, and submitted to the physician, occupational or physical therapist, podiatrist, chiropractor, or psychologist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital, or other provider of medical care, and the board.
325-1.25 (c) (2) If the employer or insurance carrier (or third-party administrator) objects to only a portion of the bill submitted, it shall pay the uncontested portion within 45 days and file objections to the remaining portion as indicated herein.
325-1.25 (c) (3) If the employer or insurance carrier (or third-party administrator) has not objected in the manner described herein to the payment of the bill within 45 days of submission, it shall be liable for payment of the full amount billed up to the maximum amount established in applicable fee schedule. The board shall not review any objection made thereafter.
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