Many Workers' Compensation Board forms are available on-line. Choose one of the following:
The HP-1 request form should be submitted when the health provider has been unsuccessful in obtaining payment from a carrier for services rendered to a patient who has a Workers' Compensation case. A minimum of 45 days must elapse after submission of the medical bill to the carrier before a request can be made. The Board suggests waiting 60 days because some carriers do make their payments on that cycle.
The attached HP-1's have been revised since the 10/1/94 version. The new HP-1 should be used for all dates of service on or after January 1, 1997. There are two choices offered through the disputed bills process. Your choice will depend upon the carrier's response (or lack of response) to your submitted bill(s).
[Box A] Administrative Award is used when an insurance carrier has not responded to your bills with a written objection within 45 days. Your HP-1 request must be received by the Board's Disputed Medical Bill (DMB) Unit within 165 days after you have submitted your bill to the carrier. The health provider must sign the HP-1 and a copy of the bill originally submitted to the insurance carrier must be attached. An Administrative Award is generated based on the established WCB medical fee schedule. The carrier will have an opportunity to respond to this award. The Board will consider that response, and based on evidence provided will either rescind or uphold the award.
[Box B] Arbitration is used when an insurance carrier has responded to your bills with a timely written objection (45 days). Be sure to submit the HP-1 form to DMB within 120 days from the time you receive the carrier's objection. Arbitration hearings will be scheduled in the order that the request is received. Both parties will receive a Notice of Hearing 30 days prior to the hearing date. A decision will be made by a panel of three providers who consider fee schedule, type of treatment and the carrier's objection. There is a cost for arbitrating. (See reverse side of HP-1 to determine arbitration fee) This fee will be added to the award amount if the disputed bill is resolved in your favor.
Recommendations: While every effort to resolve your bills with the carrier should be made before submitting an HP-1, be certain to protect your rights as there are very specific time limits for filing. Fill out the HP-1 form completely along with all necessary attachments. If you receive a C-8.1 or C-7 from the carrier, it means that there are legal issues pending. You must wait for a decision by a Board judge before requesting arbitration or administrative award. If you receive payment for your bill(s) after filing for arbitration, please submit an HP-4 withdrawal form. Please note, however, that if an HP-4 is signed after a hearing has been scheduled, the fee can not be refunded.
For more information on the HP-1 process contact Disputedmedicalbills@wcb.ny.gov