Insurance carriers attempt to limit coverage whenever possible. It is a “trick of the trade.” Insurance companies utilize defenses such as exhaustion of benefits, lack of coverage, and material misrepresentation to bar otherwise viable claims. One defense, in particular, failure to sign BOX 31 of the Health Insurance Claims Form 1500 (HICFA), is an ancient defense that is still used by certain carriers. The argument is as follows: Without a signature in BOX 31 including the Provider’s license number, the claim cannot be fully processed due to lack of notice of a covered motor vehicle accident causing injury.
What is a HICFA form?
A HICFA document is a Medicare claim form that contains, but is not limited to, a description of the medical service performed, the corresponding cost of the service, the patient’s name, the provider’s name, and facility, and most importantly, the provider’s name in BOX 31, along with his/her signature, and for purposes of the PIP statute, possibly the license number of the physician.
What is required?
Florida Statute §627.736(5)(d) (2011) reads in pertinent part:
All statements and bills for medical services rendered by any physician…clinic… shall be submitted to the insurer on a properly completed Centers for Medicare and Medicaid Services (CMS) 1500 form. All providers other than hospitals shall include on the applicable claim form the professional license number of the provider in the line or space provided for “Signature of Physician.. Including Degrees or Credentials. For purposes of paragraph (4)(b), an insurer shall not be considered to have been furnished with notice of the amount of a covered loss or medical bills due unless the statements or bills comply with this paragraph, and unless the statements or bills are properly completed in their entirety as to all material provisions with all relevant information being provided therein. (Emphasis added).
Florida Statute §627.732(13) (2011) defines “Properly Completed” as:
Providing truthful, substantially complete, and substantially accurate responses as to all material elements to each applicable request for information or statement by a means that may lawfully be provided and that complies with this section. (Emphasis added).
What do those statutes say in layman’s terms?
A PROVIDER seeking reimbursement for Personal Injury Protection benefits is required to provide truthful, substantially complete, and substantially accurate responses as to all material elements to each applicable request for information lawfully made. The provider must sign his/her name in BOX 31 of the CMS-1500 form (HICFA). The statutes request that the provider also include their license number. A license number puts the insurance company on notice that they are permitted to provide medical services and their license is active. Insurance companies have historically denied claims due to the provider failing to write in their license number in BOX 31.
Insurance carrier’s argument for the application of BOX 31 in PIP
BOX 31 is the “notice box.” Insurance companies will rely on the HICFA form to determine whether reimbursement of medical services is covered. The insurer asserts that the provider’s license should be contained in BOX 31 along with his/her signature. It follows that, without the provider’s license, the insurer will not have sufficient notice of a “covered loss.” ‘
Case law overturns its application
This is an ancient defense, and its application in today’s PIP statute world seems to be questionable at best. The insurance company has plenty of resources to determine whether or not a provider’s license is active and determine who the provider is.
- Most medical providers attach medical records with their demand Letter/HICFA. These medical records should contain the license number of the doctor/physician. This should provide the insurance company with sufficient notice of a covered loss.
- United Automobile Insurance Co. v. Professional Medical Group, Inc., 26 So. 3d 21 (Fla. 3d DCA 2009) interpreted the above statutes as such:
“A bill or statement (CMS FORM 1500) need only be substantially complete and substantially accurate as to relevant information and material provisions in order to ensure that the insurer has notice of a covered loss.” Thus, it is substantially complete and accurate if a Provider’s signature is contained in BOX 31. In this case, the Provider sent multiple medical records with the doctor/physician’s name and license. The Court held that United Automobile’s defense was not valid and that Professional Medical Group Inc. did enough to provide United with Notice of a Covered Loss. Professional Medical Group sent United medical records with the provider’s name, and United failed to challenge this as it processed the claim.
- The insurance company can simply check the webpage of the Department of Business and Professional Regulation to check a medical provider’s license.
In conclusion
It is essential to send the Insurance carrier all relevant documents to ensure that the claim is correctly processed. An experienced PIP litigation attorney will be able to formulate a plan as to what documents should be sent and when they should be delivered. However, sometimes even the most careful offices fail to send certain documents. That is why it is important to consult an experienced PIP litigation attorney to discuss the nuances of the law and to ensure that this omission does not result in the denial of a viable claim.
