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Workers' Compensation Board

New York State
Workers' Compensation Board
OFFICE OF THE CHAIR
328 State Street  Schenectady, New York 12305
Governor Andrew M. Cuomo


Subject No. 046-1136

Changes to eClaims Process for Section 21-a and Claims Paid Without Liability

Date: January 18, 2019

When a carrier is unsure of its liability with respect to a workers' compensation claim, the carrier may use Workers' Compensation Law (WCL) §21-a to extend its time to investigate the claim. WCL-§21-a permits a carrier to take up to a year (365 days) to determine whether it will accept or deny the claim when:

Use of the §21-a option has increased. In addition, on or after January 1, 2019, carriers will be required to indicate whether benefits are being paid with liability (L) and the claim is accepted or paid without liability (W) under WCL §21-a. These Agreement to Compensate codes replace the former Claim Type Codes. When a carrier selects an L on a First Report of Injury (FROI) and/or an L or W code on a Subsequent Report of Injury (SROI), the carrier is accepting the case or paying without prejudice pursuant to WCL §21-a. Accordingly, the Board has developed a process and timelines incorporating WCL §21-a rules and the eClaims protocol. Please refer to Process for Section 21-a and Claims Paid Without Liability for associated timelines, rules and process.

Ending WCL 21-a status

There are three ways to properly end a case's WCL 21-a status:

  1. Accept the case: An L filing after the first SROI with a W, indicates that the carrier has accepted the case and the case will no longer be marked as subject to WCL 21-a. The carrier should make this filing using a SROI-02.
  2. Controvert the case: A carrier that wishes to controvert the case after a W filing, must file a SROI-SJ before filing the SROI-04. Filing the SROI-SJ satisfies the carrier's obligation under WCL 21-a(3). Failure to timely or properly follow this procedure may result in a case being deemed accepted pursuant to WCL 21-a(4).
  3. Accept the case by allowing a year to pass: When the insurance carrier's initial SROI has a W designation, and 365 days have passed from the first benefit payment issue date, and the carrier has not properly controverted the case, the case is deemed accepted. The carrier must file a SROI-02 with the L designation. Once 365 days pass from the benefit payment issue date, and the carrier has not properly controverted the case, the case is deemed accepted. The carrier must file a SROI-02 with the L designation.

These changes provide effective claims management tools to streamline reporting and clarify when the carrier has accepted the claim or is reserving its right to further investigate.

 

Clarissa M. Rodriguez
Chair