assignment of benefits form ny

No Fault Assignment of Benefits AOB

An AOB, the No-Fault Assignment of Benefits form, is considered a legal and binding contract, in which the healthcare provider-assignee (i.e., the physician) assumes all of the legal rights and privileges of the injured party-assignor (i.e., the patient).  To better explain the AOB, it is wise to shed some light on the Personal Injury Protection (“PIP”) portion of automobile insurance policies.  

PIP is an extension of car insurance.  In case of injury due to a car accident, PIP covers medical expenses and, in some cases, lost wages and other damages. PIP is sometimes referred to as “No-Fault Coverage” because the statutes enacting it are generally known as “No-Fault” Laws.

PIP is designed to be paid without regard to “fault.”  That is, PIP will be paid to a person injured in a car accident even if that person was legally liable for causing the accident. PIP is also referred to as “No-Fault” because, by definition, a claimant’s or insured’s insurance premium should not increase due to a PIP claim.

When a patient wishes to receive medical treatment from a physician for injuries sustained in a car accident, he or she executes an AOB.  With the execution of this form, the treating physician assumes the benefits of the Personal Injury Protection “PIP” portion of his or her patient’s automobile policy.

Necessity and Requirement of Assignment of Benefits

The AOB form must be submitted to insurance carriers for no-fault medical treatment. It is very important that the AOB be executed properly with signatures and dates.

Can a physician bill the no-fault patient directly?

A physician who has accepted a no-fault assignment of benefits from a no-fault patient may NOT pursue the patient directly for payment even if the no-fault insurance carrier denies payment for services based upon a determination that the services were not medically necessary.  

The AOB is considered a legal contract, wherein the health provider assumes all of the legal rights and privileges of the injured party. The provider cannot arbitrarily disregard the provisions of a previously accepted no-fault assignment.   

What are a physician’s options if he or she is in disagreement with an insurer’s denial of claim?

 If the provider accepts a no-fault AOB, and the no-fault insurer denies continued treatment based on lack of medical necessity, the provider is legally bound to resolve this question of fact through either no-fault arbitration or a court of competent jurisdiction.   

What if the physician chooses not to exercise these remedies?  

Failure to exercise these remedies constitutes an acceptance of the insurer’s determination that medical services rendered to the patient were not necessary.  Under the terms of the AOB, the healthcare provider may not then bill the patient for services rendered.

Possible Revocation of Assignment of Benefits

The AOB is considered revoked if the assignor (i.e., the patient) commits a policy violation.  Insurance carriers are entitled to certain cooperation from the patient to verify submitted no-fault claims. This cooperation can include, but is not limited to, answering questions, either under oath or otherwise.  It can also include a medical examination by an independent medical examiner, commonly known as an “IME.”

If the patient refuses to cooperate with the insurance carrier (e.g., by failing to appear for an IME), or in cases where there is lack of coverage, the insurance carrier may deny the entire PIP portion of the patient’s insurance policy. In that case, the AOB will be considered revoked.  Physicians will then be able to pursue payment directly from the patient.

The possibility of revoking an AOB was clearly set forth in a May 12, 2006 opinion letter issued by the Office of General Counsel for theNew York State Insurance Department.   The relevant portion of the opinion letter states:

The assignment language found in Regulation 68-C, NYS Form NF-3 and NYS Form NF-AOB precludes the assignee from pursuing the assignor for medically unnecessary health services, unless the denial of benefits is based on a lack of coverage or violation of policy based on the conduct of the assignor.

Can the AOB Form Be Modified?

There is no need to try to get creative with the New York State AOB form.  Modifying the form to include language that would make the patient responsible to pay for services the provider renders is prohibited and will be given no legal effect.  According to the Office of General Counsel for New York State’s Insurance Department:

Statements within assignments such as “in the event that the No-Fault carrier fails or refuses to pay for the services provided then I, the patient, agree that I will be responsible for the value of services rendered by said Doctor,” are prohibited under the No-Fault regulation. Such language should be given no legal effect and the assignee may not pursue the assignor directly for unnecessary services.

To download a sample Assignment of Benefits (AOB)  form, please see our Download Section.

We are specialists in no-fault billing and collection.  To learn more from us about Assignments of Benefits, please call (516) 427-5400 for an immediate, free consultation.  

*1, http://www.dfs.ny.gov/insurance/ogco2006/rg060507.htm

Caring ‣ Urgent ‣ Aggressive

• Call For A Free Legal Consultation: (201) 261-1700
• Physician Reimbursement
• PIP / No-Fault Arbitration
• Workers’ Compensation Recovery
• Hospital Reimbursement
• ERISA Litigation Claim Attorneys
• Healthcare Arbitration
• Bicycle Accident
• Brain Injury
• Bus Accident
• Car Accident
• Construction Accident
• Hit and Run
• Motorcycle Accident
• Negligent Supervision
• Nursing Home Negligence
• Pedestrian Accident
• Slip and Fall
• Truck Accident
• Train Accident
• Wrongful Death
• Workers Compensation
• Business Disputes
• Business Justice Attorneys
• Employment Counseling and Litigation
• Shareholder/Partner Issues
• Shareholder Derivative Actions
• Business Dissolutions
• Business Transactions
• Buying/Selling a Business
• Corporate Entity Formation
• Director and Officers Duties
• Executive Compensation
• Negotiating Vendor Agreements
• Regulatory and Statutory Compliance
• Age Discrimination
• Disability Discrimination
• Gender Identity Discrimination
• Race Discrimination
• Religious Discrimination
• Sex Discrimination
• Appellate Law
• Child Custody
• Child Custody College Expenses
• Child Support
• Divorce for Business Owners
• Divorce Mediation
• Domestic Violence
• Prenuptial Agreements
• Property Distribution
• Understanding The Divorce Process
• Auto Insurance/Property Damage
• All-risks Property Insurance
• Commercial General Liability (CGL) Insurance
• Disability Insurance
• Health Insurance
• Insurance Agent/Broker Negligence
• Life Insurance
• Long-term Care Insurance
• Marine/Boat Insurance
• Wind & Flood Property Insurance
• Commercial Purchase
• Commercial Sales
• Commercial Lease Agreement
• First-Time Home Buyer
• Lease Agreements
• Real Estate Closing
• Refinancing
• Residential Purchases
• Residential Sales
• Title Review
• Estate Planning
• Estate Planning for Business Owners
• Healthcare Directives
• Powers of Attorney
• Trust Drafting
• Will Contest
• Will Drafting
• Sean Callagy Esq
• The Callagy Law Team
• Testimonials
• Join Our Team
• Message of Empathy
• Business Law
• Commercial Litigation
• News & Events
• Medical Revenue Recovery
• Personal Injury
• Free Legal Guides
• Paramus, NJ Office
• New York, NY Office
• Phoenix, AZ Office
• East Hanover, NJ Office

Call For A Free Legal Consultation

(201) 261 - 1700

Insurance claims , medical revenue recovery, what should an assignment of benefits form include.

An assignment of benefits form (AOB) is a crucial document in the healthcare world. It is an agreement by which a patient transfers the rights or benefits under their insurance policy to a third-party – in this case, the medical professional who provides services. This way, the medical provider can file a claim and collect insurance payments. In the context of personal injury protection coverage, an AOB is a critical step in the reimbursement process.

Personal injury protection coverage , or PIP, is designed to cover medical expenses and lost wages incurred after an auto accident, regardless of who is at fault. In New Jersey, drivers are required to carry PIP. Now, let’s say there’s an accident: the driver sees a medical provider for treatment, and the provider bills the patient’s carrier. There is nothing that requires that the insurance carrier to pay the provider. 

This is why an assignment of benefits form is so important. It essentially removes the patient from the equation and puts the medical provider in their place as far as the insurance policy is concerned. This enables the provider to be paid directly. If you see PIP patients and want to be paid directly by the insurer (and avoid claim denials or complex legal situations later) you must get an AOB.

The AOB authorization creates a legal relationship between the provider and the insurance carrier. What should it include?

• Correct Business Entity

Fill out your business name correctly: it seems simple, but this can be a stumbling block to reimbursement. If your business name is Dr. Smith’s Chiropractic Care Center, you cannot substitute Dr. Smith’s, Smith’s Chiropractic, etc.  It must be Dr. Smith’s Chiropractic Care Center. If you have a FEIN number, use the name that is listed on your Health Care Financing Administration (HCFA) form.

• “Irrevocable” 

It is important that you include this term to indicate that the patient cannot later revoke the assignment of benefits. This tells the court that the AOB is the only document determining standing , or the ability to bring a lawsuit on related matters.

Another key term: the court sees benefits as payments. It does not necessarily give you the right to bring a lawsuit. Include language such as, “assigns the rights and benefits, including the right to bring suit…” 

• Benefit of Not Being Billed At This Time for Services

Essentially, this means that a provider gives up the right to collect payments at the time of service in exchange for the right to bring suit against the insurance company if they are not paid in full. Likewise, the patient gives up the right to bring suit, but they do not have to pay now. The wording will look like this: “In exchange for patient assigning the rights and benefits under their PIP insurance, Dr. Smith’s Chiropractic Care Center will allow patients to receive services without collecting payments at this time.”

• Patient Signature 

Yes, it’s basic, but make sure the assignment of benefits form is signed and dated by the patient! This renders the AOB , for all intents and purposes, null and void. It is not an executed contract. You would have to start the entire process again, which means waiting longer to be reimbursed for the claim. 

• Power of Attorney Clause

Including a power of attorney clause, which supports not only “the right of collecting payment” but also the provider’s ability to take legal action on behalf of the patients, is vital. At Callagy Law, we always argue this is inherent within the no-fault statute; however, there are carriers to argue against the right to arbitration when the language is not in the AOB.

As medical providers, it is critical that you receive proper – and timely – reimbursement for services rendered. The assignment of benefits form is one of the most important pieces in this puzzle. It is essential for an attorney to prepare, or at least review, your AOB and other admission paperwork to ensure that you are able to collect pursuant to your patients’ insurance benefits in whatever ways needed. 

Callagy Law can not only review these documents, but also ensure you are pursuing all recoverable bills to which you are eligible. If you have any questions, would like us to review your AOB form, or have issues collecting payment from insurance companies, please contact the Callagy Law team today .

Leave a Reply

Your email address will not be published. Required fields are marked *

• Wind & Flood Property Insurance
• FREE LEGAL GUIDES

• Skip to main content
• New York Rate Filing notices
• Emergency Services and Surprise Bills
• FAIR Health notice
• New York Executive Order - Monkeypox
• NYAG and United Behavioral Health Outpatient Services Settlement Information

Information for members of New York Insurance Plans: Emergency Services and Surprise Bills

What is a surprise bill.

A surprise bill is a bill you receive for covered services performed by a non-participating (out-of-network) health care provider in the following circumstances:

• The out-of-network provider performs services at a participating (network) hospital or ambulatory surgery center and:
• A network doctor is not available at the time the health care service was performed; or
• An out-of-network provider performs services without your knowledge.
• A network provider refers you to an out-of-network provider without your written consent. If your plan does not require referrals, a surprise bill only occurs in limited circumstances. For example, when during your office visit a network doctor brings in an out-of-network provider or sends bloodwork to an out-of-network laboratory without your written consent.
• You receive out-of-network (OON) emergency hospital services, including inpatient services following an emergency room visit.

A surprise bill does not include a bill for health care services when you choose to see an out-of-network provider.

What is an out-of-network provider?

An out-of-network provider is a doctor, health care professional, or facility (like a hospital or ambulatory surgery center) who isn’t part of your plan network. You may pay more for services you get from out-of-network providers.

What happens when I use an out-of-network provider?

Your costs may be higher. A facility must inform you if any out-of-network providers will be involved in your care. If you are not informed, you will only be responsible to pay your in-network deductible, co-pay or co-insurance amount. A surprise bill does not include a bill for health care services when you agree to see an out-of-network provider.

If I go to a network hospital will all of the providers be in the network?

Maybe. Sometimes specialists like emergency room doctors, anesthesiologists, radiologists or pathologists are not part of your network. For example, if you go to a network hospital and get an X-ray, the doctor reading the X-ray may not be in the network.

How do I make sure I receive care from a network provider?

When receiving care, please make sure to ask that all services you receive are from network providers. You should also confirm that any new doctor or health care provider is in the network for your plan.

To find a network provider:

• Log into myuhc.com ® and select Find a Provider; or
• Call us at the phone number on your health plan ID card, and we’ll be happy to help.

What if I have an emergency?

You should go to the nearest emergency room for treatment.

How much will I be responsible to pay for emergency and surprise bills?

For either a surprise bill or emergency services, you will only be responsible to pay your in-network deductible, co-pay or co-insurance amount. We may initially pay the claim at the out-of-network level until further information is provided.

What should I do if I get a surprise bill or a bill for emergency services?

If you receive a bill from an out-of-network provider and believe it is a surprise bill or a bill for emergency services, do not pay the provider. Call the phone number on your health plan ID card. We may request that you submit additional information needed to determine whether it is a surprise bill. If you receive a surprise bill, you will need to fill out and submit the New York State Out-of-Network Surprise Medical Bill Assignment of Benefits Form.  The form and instructions are available at https://dfs.ny.gov/search/site?search=assignment+of+benefits+form . 

We may attempt to negotiate with the provider or pay an additional amount to resolve the claim. If we pay more, your cost share may increase.

Where should I send the New York Assignment of Benefits form?

Please send the completed New York Assignment of Benefits form and a copy of the bill to UnitedHealthcare at the address listed on your health plan ID card, or submit electronically at https://nyrmo.optummessenger.com/public/opensubmit .

What if the provider disagrees with the amount paid?

If the provider disagrees, the provider may submit the dispute for review through New York’s independent dispute resolution process. After the dispute is resolved, your cost share may increase if the health plan is told they must pay additional amounts.

What is the independent dispute resolution process?

New York will select an independent dispute resolution entity (IDRE) to review claims for emergency services and surprise bills where the payment amount can’t be agreed upon. The IDRE will receive information about the services received and determine the reasonable fee for the services. The IDRE will issue a decision accepting either our payment amount or the provider’s billed charge. For surprise bills, a dispute may be submitted to the IDRE for review by a health care plan, an out-of-network physician, an out-of-network referred health care provider, or an insured who does not assign benefits by completing the NY AOB form. To submit a dispute to the IDRE, complete the application found at NYS IDR Provider and Insurer Application .

If you have questions, please call the member phone number on your health plan ID card.