New York No-Fault Fee Schedule: Caps, Deadlines, and Disputes

The New York no-fault fee schedule caps what medical providers can charge when they treat injuries from a car accident, tying those maximum charges to the rates set by the Workers’ Compensation Board. Every driver in the state carries a mandatory $50,000 in no-fault coverage, and the schedule exists so that money pays for as much treatment as possible instead of being consumed by inflated billing.¹ For an injured driver, the practical result is that your benefits buy more care, your provider cannot send you a bill for the difference, and the rules governing what gets paid, when, and how disputes get resolved are all set by regulation rather than left to negotiation.

What the Schedule Caps and What It Doesn’t

Section 5108 of the New York Insurance Law is the source of the cap. Charges for medical services arising from a motor vehicle accident cannot exceed the rates the chair of the Workers’ Compensation Board has set for industrial accidents. The only escape valve is when an insurer or arbitrator decides that an unusual procedure or unique circumstance justifies a higher charge, and that exception is used sparingly.²

The Department of Financial Services runs the details through 11 NYCRR Part 68, known as Regulation 83. Where no Workers’ Compensation schedule exists for a service, the superintendent of financial services creates one after consulting with the WC Board chair and the commissioner of health.³

Your $50,000 in coverage is not all medical money. It also pays lost earnings up to $2,000 per month for up to three years, reduced by any disability benefits your employer provides, and other reasonable expenses up to $25 per day for up to one year. Medical expenses covered include hospital, surgical, dental, ambulance, prescription drug, physical and occupational therapy, psychiatric, and prosthetic services, with no time limit as long as it is ascertainable within one year of the accident that further costs will be incurred.¹ All of it comes out of the same $50,000. The fee schedule is what keeps the medical share from eating everything else.

How the Rates Are Calculated

Each procedure has an assigned unit value that reflects its complexity and the resources it requires. That unit value is multiplied by a dollar conversion factor to produce the maximum charge.⁴

New York is split into four geographic regions with different conversion factors, so the same procedure pays more in New York City than in a rural upstate county. The region is set by the ZIP code where the service was performed, not where you live or where the accident happened.⁴ Services are billed using CPT codes; diagnoses use ICD-10-CM.

Rates also depend on the type of license the provider holds, not who employs them. Regulation 83 keeps separate schedules for physicians, chiropractors, physical therapists, occupational therapists, psychologists, and social workers, and dental care follows its own schedule. A chiropractor working in a physician’s office is paid at the chiropractic rate. The narrow exception is where a Workers’ Compensation ground rule says otherwise, as under Ground Rule Nine of the Physical Medicine Fee Schedule for physical and occupational therapists employed by a physician.²

Durable Medical Equipment

Crutches, braces, prosthetic appliances, orthopedic footwear, and surgical supplies do not follow the WC unit-value formula. The maximum charge is capped at whatever Medicaid would pay for that same item at the time it is provided.² The result tends to be lower reimbursement than the clinical service schedules, which is a common complaint among DME suppliers.

Prescription Drugs

Prescriptions use Average Wholesale Price as the baseline. Brand-name drugs are reimbursed at AWP minus 12% plus a $4 dispensing fee. Generics are AWP minus 20% plus a $5 dispensing fee. The actual payment is the lesser of that calculated cost, any contract price the pharmacy has with the insurer, or the pharmacy’s usual and customary charge.⁵

Providers Cannot Bill You for the Difference

This is the piece of the schedule most worth knowing as an injured driver. A provider who treats you for a car accident injury cannot send you a bill for the gap between their usual rate and the fee schedule amount. The schedule rate is the full payment. By treating you under the no-fault system, the provider accepted those terms.⁶ A balance bill for a service covered by no-fault violates Section 5108.

The protection covers every service the schedule reaches, from physician visits to chiropractic care, physical therapy, mental health treatment, and prescriptions. It does not reach services that fall outside no-fault entirely, such as cosmetic procedures unrelated to the accident.

The Deadlines That Control Payment

Providers submit no-fault claims on standardized New York State forms. The NF-3 is the verification of treatment form used by physicians and every other non-hospital provider. Hospitals use the NF-4 and NF-5.⁷

Written proof of claim must reach the insurer as soon as reasonably practicable, and no later than 45 days after the service was rendered.⁸ Insurers reject late submissions and courts have upheld those rejections.

Once the insurer has a complete claim with all requested verification, it has 30 calendar days to either pay or deny. Anything unpaid after that window is overdue.⁹ The catch is that “complete claim” language. Within 15 business days of receiving the initial forms, the insurer can request additional verification, and that request pauses the 30-day clock until the provider responds. If the provider does not respond within 30 calendar days, the insurer must send a follow-up within 10 calendar days.¹⁰ Many claims stall inside this verification loop, so submission and response dates matter.

If part of a claim is disputed and part is not, the insurer still has to pay the undisputed part. It cannot hold everything back to fight over a piece.⁹

Overdue benefits collect interest at 2% per month, pro-rated on a 30-day month.¹¹ That is 24% a year, set deliberately high to discourage insurers from stalling. It applies both to the injured person and to any provider who has taken an assignment of benefits. Collecting it depends on being able to show exactly when the claim tipped into overdue status.

Assignment of Benefits

Most providers do not want to wait while you collect your benefits and forward the money. They will ask you to sign an assignment of benefits form, the NF-AOB, which transfers your right to payment directly to the provider. The insurer then pays the provider, and the provider runs the claim.¹²

Once you sign, the provider cannot come after you for payment on those assigned services, regardless of anything else you may have signed. The provider’s recourse is against the insurer. The provider can revoke the assignment only if benefits are not payable because you lack coverage or you violated a policy condition through your own actions.¹²

Where Insurers Push Back: IMEs and Peer Review

Most cutoffs of no-fault benefits happen through one of two mechanisms.

The first is the independent medical examination. Insurers can require you to attend a medical examination with a doctor of their choosing, as often as they reasonably see fit, and they must schedule the exam within 30 calendar days of receiving the initial verification forms. Skipping an IME is treated as a failure to meet a condition precedent for coverage. The insurer can then deny not only the pending claim but all future claims for medical services from the same accident. Benefits already paid before the missed exam are safe; the insurer cannot claw those back. Everything after is at risk. One safeguard: the insurer cannot suspend ongoing payments while an IME is pending unless the scheduling delay is the claimant’s fault or the fault of the claimant’s attorney.¹³

The second mechanism is peer review. The insurer sends your medical records to a licensed provider in the same or similar specialty, who reviews the file and issues an opinion on whether the care is appropriate and necessary. The reviewer never examines you; the call is made from the paperwork.¹⁴ If the reviewer says treatment is no longer necessary, the insurer issues a denial. This is the tool behind most benefit cutoffs, and it shows up most often with chiropractic care and physical therapy weeks or months into treatment, when the reviewer concludes the patient should have recovered.

Disputing a Denial

Denials are handled by the American Arbitration Association in two steps. Conciliation comes first, an informal attempt to resolve the dispute. If nothing resolves within 45 days, the case moves to a formal arbitration hearing.¹⁵

Request arbitration within 90 days after the claim became overdue or within 90 days after receiving the denial, and the hearing must be scheduled within 45 days of the conciliation center’s referral. Arbitrators are New York-licensed attorneys with at least five years of relevant experience.¹⁵

If the arbitrator rules for the claimant, the insurer has 30 calendar days to pay. The insurer can appeal to a master arbitrator, but only on limited grounds such as an award exceeding policy limits or a procedural error rising to the level of misconduct. Filing the appeal stays payment until the master arbitrator decides.

1
New York State Department of Financial Services. How Much Auto Insurance Must I Carry
2
Department of Financial Services. Twenty-Eighth Amendment to Regulation 83 (11 NYCRR 68)
3
Cornell Law Institute. New York Comp Codes R and Regs Tit 11 65-3.16 – Measurement of No-Fault Benefits
4
New York Codes, Rules and Regulations. New York Codes, Rules and Regulations – Workers Compensation Fee Schedule Ground Rules
5
New York Codes, Rules and Regulations. Workers Compensation Pharmacy Fee Schedule
6
Department of Financial Services. FAQ – Regulation 83 and the No-Fault Fee Schedule
7
Department of Financial Services. No-Fault Information for Insurers
8
Department of Financial Services. OGC Opinion – Time Requirement to Submit Medical Proof of Claim to Insurer
9
Cornell Law Institute. New York Comp Codes R and Regs Tit 11 65-3.8 – Payment or Denial of Claim
10
Department of Financial Services. OGC Opinion No 07-11-11 – No-Fault Documentation and Social Services
11
Cornell Law Institute. New York Comp Codes R and Regs Tit 11 65-3.9 – Interest on Overdue Claims
12
Department of Financial Services. New York Motor Vehicle No-Fault Insurance Law Assignment of Benefits Form
13
NY Courts. Failure to Attend a No-Fault IME
14
Department of Financial Services. OGC Opinion No 04-10-01 – No-Fault Peer Review Organizations
15
Cornell Law Institute. New York Comp Codes R and Regs Tit 11 65-4.5 – No-Fault Arbitration