ROCKLAND FAMILY MEDICAL CARE v. STATE FARM MUTUAL AUTOMOBILE INS CO (2022)

ORDERED that the order, insofar as appealed from, is modified by providing that the branch of defendant's motion seeking summary judgment dismissing so much of the complaint as sought to recover upon the claim for services rendered on June 10, 2014, which was billed under CPT code 99205, is denied, and, upon a search of the record, summary judgment is granted to plaintiff upon that claim in the principal sum of $97.14; as so modified, the order, insofar as appealed from, is affirmed, without costs.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff appeals, as limited by its brief, from so much of an order of the Civil Court as granted the branches of defendant's motion seeking summary judgment dismissing so much of the complaint as sought to recover upon claims for services billed under CPT code 99212, on the ground that the amount plaintiff sought to recover exceeded the amount permitted by the workers’ compensation fee schedule; claims for services rendered on June 2, 2014, June 9, 2014, June 10, 2014, July 15, 2014, November 18, 2014, December 31, 2014, March 30, 2015, May 28, 2015, and July 29, 2015, on the ground that defendant had paid those claims in full; and claims for services purportedly rendered on October 6, 2014 ($71.40), October 6 to October 22, 2014 ($334.60), and October 13 to October 22, 2014 ($394.44), on the ground that defendant had not received those claims.

Defendant supported its motion with affidavits by its claim specialist and an independent certified professional coder, which affidavits were sufficient to establish, prima facie, with respect to the claims for services billed under CPT code 99212, that the amount plaintiff sought to recover exceeded the amount permitted by the workers’ compensation fee schedule. In opposition, plaintiff failed to raise a triable issue of fact, as plaintiff submitted only an affirmation by its counsel, who did not establish that he possessed personal knowledge of the facts. However, defendant's moving papers establish that defendant was not entitled to summary judgment dismissing so much of the complaint as sought to recover upon the claim for services rendered on June 10, 2014, which was billed under CPT code 99205. As set forth in the affidavits defendant submitted from its claim specialist and the certified professional coder, plaintiff was entitled to $97.14 for that claim, which defendant had denied in full. Consequently, upon a search of the record (see Merritt Hill Vineyards v Windy Hgts. Vineyard, 61 NY2d 106 [1984]), we find that plaintiff is entitled to summary judgment upon that claim in the principal sum of $97.14.

With respect to the bills for services rendered on June 2, 2014, June 9, 2014, July 15, 2014, November 18, 2014, December 31, 2014, March 30, 2015, May 28, 2015, and July 29, 2015, defendant demonstrated, through the submission of checks to plaintiff which plaintiff had endorsed, that defendant had paid those bills in full, and plaintiff failed to raise a triable issue of fact with respect thereto.

With respect to the bills for services purportedly rendered on October 6, 2014, October 6 to October 22, 2014, and October 13 to October 22, 2014, the affidavit by defendant's claim specialist contained more than a mere conclusory denial of receipt of the claim forms allegedly mailed to defendant (cf. Top Choice Med., P.C. v GEICO Gen. Ins. Co., 33 Misc 3d 137[A], 2011 NY Slip Op 52063[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2011]) and sufficiently established, prima facie, that defendant had not received those claim forms (see Matter of Government Empls. Ins. Co. v Morris, 95 AD3d 887 [2012]). In the absence of a sworn statement sufficient to demonstrate, prima facie, plaintiff's submission of the claim forms at issue, defendant was entitled to summary judgment dismissing so much of the complaint as sought to recover upon those claims (see Natural Therapy Acupuncture, P.C. v Interboro Ins. Co., 36 Misc 3d 135[A], 2012 NY Slip Op 51350[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2012]; Fiveborough Chiropractic & Acupuncture, PLLC v American Employers’ Ins. Co. Div. of Onebeacon Am. Ins. Co., 24 Misc 3d 133[A], 2009 NY Slip Op 51395[U] [App Term, 2d Dept, 9th & 10th Jud Dists 2009]).

Accordingly, the order, insofar as appealed from, is modified by providing that the branch of defendant's motion seeking summary judgment dismissing so much of the complaint as sought to recover upon the claim for services rendered on June 10, 2014, which was billed under CPT code 99205, is denied, and, upon a search of the record, summary judgment is granted to plaintiff upon that claim in the principal sum of $97.14.

ALIOTTA, P.J., WESTON and BUGGS, JJ., concur.