An insurance company must send its first request within 30 days of receiving your bill. If the carrier does not receive a verification response from you within 30 days of sending its request, the carrier must send a follow-up request within 10 calendar days.
Carriers are entitled to receive any information it deems necessary to verify the bill. Requests should have a rational and reasonable relationship to the bill. In layman’s terms, the verification request must be relevant to the carrier’s decision on whether to pay or deny the claim.
For example, the courts have ruled that an insurance company did not have a good faith basis to request a color photograph of surgery in order to process a bill.
A medical provider has 120 calendar days to respond to an insurance company request for verification.
Late verification responses may still be entitled to payment if the insurance company fails to meet certain criteria. To determine whether you can receive payment for claims with a late verification response, contact an attorney in our no-fault collections law firm network.
A medical provider only needs to submit documents in its possession. The insurance company may be required to issue a payment or deny a bill, even if the carrier doesn’t receive all the request documents.
Yes. Even when the insurance company requests documents that have no relationship to the bill or claim, the medical provider must communicate its objection to the insurance company within a proper verification response letter and within 120 days. Failure to provide a verification response will result in a waive of the defense that the request was unreasonable.
If a medical provider only providers some of the response, the insurance company will either pay, issue a denial or send another letter acknowledging the information received and requesting missing information
If a verification request is confusing, the medical provider’s verification response should ask for clarification. The insurance company is obligated to clarify the requested information once it received a verification response. The insurance company fails to clarify the verification request, the bill can be viewed as improperly tolled.
No. All verification requests must be requested within 30 days of the insurance company receiving the bill.
Yes, an insurance company may delay your claims because the insurance company required information from a third-party provider. However, the missing information must be relevant to the payment of your bill.