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HIMP Rules and Regulations


§ 325-5.1 Statement of purpose

The purpose of subdivisions (d) and (h) of section 13 of the Workers' Compensation Law and this Subpart is to assist health insurers and health benefits plans to set up a system to identify claims that they have paid which may be the responsibility of the employer, workers' compensation insurance carrier, or special fund, and to obtain reimbursement therefore.

§ 325-5.2 Eligibility

Only a health insurer or health benefits plan, as defined by paragraph (1) of subsection (d) of section 13 of the workers' compensation law, and its legal representatives, agents and contractors, shall be eligible to participate in this program. Collection agencies, and other like entities, are not eligible to participate in the match program, as defined in this Subpart. For the purpose of this Subpart, collection agencies and other like entities are defined as those agencies and entities that seek to recoup medical and hospital payments directly from the claimant.

§ 325-5.3 Introduction and overview

The Board shall conduct computer searches at least quarterly upon the request of health insurers or health benefits plans, upon their full compliance with these regulations. Health Insurers and health benefits plans desiring such searches shall submit to the Board the required information including all data elements in a technological format acceptable to the Board. Such information shall be compared with the computer records of the Board, in order to identify employees whose social security numbers, name, date of accident, ZIP codes or other qualifiers match.

§ 325-5.4 Definitions

Accident, where used in this Subpart, shall include both accidents arising out of and in the course of employment and occupational diseases. In the case of occupational disease, date of accident, where used in this Subpart, shall mean date of disablement.

§ 325-5.5 Confidentiality of information

  1. Misuse of confidential information; penalties. A health insurer or health benefits plan receiving information pursuant to subdivision (h) of section 13 of the Workers' Compensation Law and this Subpart shall use such information solely for the purpose of reimbursement from the employer, workers' compensation insurance carrier or special fund. Upon notification to the secretary that a health insurer or health benefits plan has used such information for purposes other than that stated above, an administrative hearing shall be held before an employee of the board, designated by the chair to conduct such hearings. The chair, upon a finding that such information has been used by a health insurer or health benefits plan for purposes other than that stated above, may, after such hearing, impose a penalty of not more than $ 10,000, and may prohibit such health insurer or health benefits plan from receiving information under subdivision (h) of section 13 of the Workers' Compensation Law and this Subpart, with reference to claims which arise during a period of up to three years.
  2. Pooling of requests for computer searches permitted. Each health insurer or health benefits plan wishing to have searches conducted pursuant to subdivision (h) of section 13 of the Workers' Compensation Law and this Subpart shall submit the request in a technological format acceptable by the Board which shall include claims from such health insurer or health benefits plan. Pooling of requests for computer searches, by groups of health insurers or health benefits plans, shall be permitted, but must specifically indicate the individual health insurer or health benefits plan to be placed on notice in accordance with section 325–5.6(b)(1) of this Subpart. The Board shall respond to such requests for computer searches in accordance with section 325–5.6(c) of this Subpart.

§ 325-5.6 General procedure

  1. Format of requests for computer searches. Health insurers and health benefits plans that are interested in participating in the match program shall submit requests for computer searches in a technological format acceptable to the Board. Such requests for computer searches shall include the claimant's social security number, last name, initial of first name, sex, ZIP code, and date of treatment or date of accident, if known. If the request made does not include a social security number, a search will be attempted using the claimant's last name, initial of first name, sex, ZIP code, and date of treatment or accident. When a match request is made by using the claimant's social security number, the claimant's first initial of the first name will not be part of the matching criteria. In regard to the date of treatment or accident submitted by the health insurer or health benefits plan, this date will be matched against the date of accident contained in the Board's file, and will result in a match on this criterion if the date of treatment or accident submitted by the health insurer or health benefits plan is within 30 days of the date of accident contained in the Board file.
  2. Match situations.
    1. Full match. When there is a "full match," the Workers' Compensation Board will provide the health insurer or health benefits plan with the following information:
      1. the workers' compensation case number;
      2. a description of the injury or illness (if and as available in the board's computer database);
      3. the workers' compensation carrier's identification number (carrier code);
      4. the workers' compensation carrier's case number (if and as available in the board's computer database);
      5. a designation as to whether accident, notice and causal relationship (ANCR) has been established (if and as available in the board's computer database); and
      6. a designation as to whether the case is open or closed (if and as available in the board's computer database).
      If there is a full match, the health insurer or health benefits plan will be placed on notice for future hearings and decisions. A health insurer or health benefits plan will only be placed on notice for future hearings and decisions in cases where there is a full match. A health insurer or health benefits plan which has been placed on notice in a case in which accident, notice and causal relationship has not been established, or in which the case has been closed by a Workers' Compensation Law judge without establishing accident, notice and causal relationship, shall remain on notice until all administrative and judicial appeals available to the party seeking to establish the compensability of the claim have been exhausted.
    2. Partial match. When there is a "partial match," the Workers' Compensation Board will provide the health insurer or health benefits plan with the following information:
      1. the workers' compensation carrier's identification number (carrier code);
      2. the workers' compensation carrier's case number (if and as available in the board's computer database); and
      3. identification of the fields that failed the "full match" process.
      In such a situation, the health insurer or health benefits plan shall not receive copies of hearing and decision notices and shall not be provided with the claimant's workers' compensation case number, a description of the injury or other personal information.
    3. No match. A "no match" occurs when sufficient matching data is not available for either of the above two situations. Where there is a "no match," no information is provided to the health insurer or health benefits plan on that record or request.
  3. Return of requests for computer searches.. The health insurer's or health benefits plan's initial request for computer searches will be returned unchanged, along with a separate file, notifying the insurer of the information on "full" and "partial" matches. The Board will make every effort, barring unforeseen circumstances, to respond to the health insurer's or health benefit plan's search request and return the health insurer's or health benefits plan's initial request for computer searches within 30 days of its receipt. Where a pooled submission is made by a group of health insurers and/or health benefits plans, the Board will issue separate response files to each health insurer and/or health benefits plan which will contain information relating only to its individual search requests.
  4. Availability of information in Board files.
    1. When a health insurer or health benefits plan has been notified of a "full match" pursuant to paragraph (b)(1) of this section, such health insurer or health benefits plan may make a request in writing to the Board for any information in the Board files as may be relevant to any bill that has been paid by such insurer or health benefits plan. Such requests shall be submitted to the Workers' Compensation Board, Attention: HIMP Coordinator, State Office Building, 44 Hawley Street, Binghamton, NY 13901.
    2. Upon receipt of a written request by a health insurer or health benefits plan pursuant to paragraph (1) of this subdivision, the board files shall be reviewed by board personnel to determine which, if any, documents, reports, records and/or other materials contained therein are relevant and/or necessary to the health insurer's or health benefits plan's request for reimbursement. Copies of all such documents, reports, records and/or other materials contained therein determined to be relevant and/or necessary by board personnel shall be made available to the health insurer or health benefits plan requesting such information, provided, however, that no copies of such information shall be made available to a health insurer or health benefits plan with respect to any compensation claim which has been closed without findings of accident, notice and causal relationship. In such cases where the case has been closed without findings of accident, notice and causal relationship, the board shall so advise the health insurer or health benefits plan in writing. The costs of photocopying documents, reports, records and/or other materials from board files shall be borne by the health insurer or health benefits plan.
  5. Age of claims to be submitted. Requests for computer searches submitted on or prior to March 3l, 1992 may be submitted with a payment date on or after April 1, 1988. Requests for computer searches submitted after March 31, 1992 must have a payment date which is no earlier than three years prior to the date of submission of the claim to the board for matching purposes.

§ 325-5.7 Payment for searches; process for submission of search requests

  1. Fees. The Board will charge a health insurer or health benefits plan for each search request submitted through the computer match process, and/or for any manual review of the case file. The cost of searches shall be computed based on actual costs to the Board. Where multiple searches of the same record are required, there shall be a charge for each search.
    1. Computer searches. The cost of computer searches shall be computed based on the actual costs to the Board. For the purposes of computing the costs for computer searches, the costs shall include the actual search by computer to determine whether there is a full match pursuant to section 325–5.6(b)(1) of this Subpart. In its submission to the Board, the health insurer or health benefits plan must include, at the end of the file, the total number of records or requests on that file. Payment, at the initial rate of $0.043 per search, must immediately follow the submission of the file. Payment is to be in the form of a standard or certified check made payable to: The New York State Workers' Compensation Board and sent to the Workers' Compensation Board, Attention: Finance Office, 20 Park Street, Albany, NY 12207. After the search or searches, the Board will recompute the cost for the search or searches based on the actual cost of the search or searches and on the actual number of searches performed. Following such computation, the Board will bill the health insurer or health benefits plan for the amount that the actual cost of performing such search or searches exceeds the amounts submitted by the health insurer or health benefits plan, and/or if the number of searches conducted exceeds the record count on which the health insurer or health benefits plan computed payment. If there is an overpayment on the part of the health insurer or health benefits plan, the Board will issue a refund for the overpaid amount or, if requested by the health insurer or health benefits plan, use the overpayment as a credit against future submissions.
    2. Review of file after full match.The charge for manual review by the Board of Board files which may be necessary to provide the health insurer or health benefits plan with the information specified in section 325–5.6(d)(2) of this Subpart once a full match has been determined will be at the rate of $1.795 per search. In its request for review of the files, the health insurer must include the total number of searches requested and payment at the rate of $1.795 per search must accompany the request. Payment is to be in the form of a standard or certified check made payable to: The New York State Workers' Compensation Board.
    3. Manual search. The charge for a manual search of Board records by the Board will be $25 per search. Payment must accompany the request for a manual search and is to be made in the form of a standard or certified check made payable to: The New York State Workers' Compensation Board. The review of the Board files pursuant to section 325–5.6(d)(2) of this Subpart shall not be deemed a manual search for the purpose of this paragraph.
  2. Submission of tapes; payment. Computer tapes (or requests for manual processing) submitted as part of this program shall be accompanied by a letter from the health insurer or health benefits plan, on the health insurer's or health benefits plan's letterhead, identifying the submission, including information on the number of claims submitted and the total initial cost as per the rates cited in paragraphs (a)(1) and (2) of this section. Search requests shall be submitted to the Workers' Compensation Board, Attention: Director of Workers' Compensation Accounts (Health Insurance Match Program), 100 Broadway--Menands, Albany, NY 12241.

§ 325-5.8 Provision of notice

Notice of the results of a computer match shall be provided by the board, to a health insurer or health benefits plan, in accordance with subdivision (h) of section 13 of the Workers' Compensation Law and section 325-5.6(c) of this Subpart. The board shall respond to requests for manual searches, in accordance with subdivision (h) of section 13 of the Workers' Compensation Law, in writing.

§ 325-5.9 Waiver of timely submission of bills

Sections 325-1.20(b), 327.2(c), 328.3(c), 342.2(c), 347.3(b) and 349-2.3(b) of this Title shall not apply where there is a "full match" under section 325-5.6 of this Subpart.

§ 325-5.10 Reimbursement from compensation carrier

A health insurer or health benefits plan requesting reimbursement shall file such requests in accordance with the provisions of Subpart 325-6 of this Title.

§ 325-5.11 Annual reporting

No later than March 31st of each year, each health insurer or health benefits plan participating in this program shall send a report to the chair indicating the total amount recovered in the prior calendar year as a result of this program.

§ 325-6.1 Definitions

As used in this Subpart:

  1. "Chair" shall mean the Chairman, Chairwoman or Chair of the Workers' Compensation Board of the State of New York.
  2. "Board" shall mean the Workers' Compensation Board of the State of New York.
  3. "Accident" shall mean an accidental injury arising out of and in the course of employment or occupational disease as defined in the Workers' Compensation Law.
  4. "ANCR" shall mean accidental injury or occupational disease, notice and causal relationship.
  5. "Carrier" shall mean a self-insured or uninsured employer, workers' compensation insurance carrier or special fund created by the Workers' Compensation Law for payment of workers' compensation claims, but shall not include the uninsured employers' fund.
  6. "Dispute forum" shall mean the American Arbitration Association or such other private arbitration association or forum for alternative dispute resolution designated by the chair to arbitrate disputed requests for reimbursement.
  7. "Health insurer" shall mean a health insurer, health benefits plan or other payor of health benefits as defined in section 13(d) of the Workers' Compensation Law.
  8. "Provider" shall mean a physician, hospital, physical or occupational therapist, podiatrist, chiropractor, psychologist or other health provider.
  9. "Proof of service" shall mean an affidavit of service by regular mail or personal delivery, or proof of mailing by certified or registered mail.

§ 325-6.2 Filing requests for reimbursement

  1. The health insurer shall be solely responsible for initiating claims for reimbursement of amounts paid by them which may be the responsibility of the carrier, as provided in section 13(d) of the Workers' Compensation Law. The health insurer shall develop with the carrier its own mechanisms and standard operating procedures for payment of undisputed claims for reimbursement.
  2. Claims for reimbursement must be filed within three years of the date of payment by the health insurer for services rendered by a provider or by October 15, 1992, whichever is later, as provided in section 13(d) of the Workers' Compensation Law. Requests for reimbursement are filed by:
    1. submission of a request for computer searches to the Board, pursuant to Subpart 325–5 of this Part, to identify claims which may be the responsibility of the carrier; or
    2. submission to the carrier of a form prescribed by the chair (HIMP-1) requesting reimbursement in accordance with section 325-6.3 of this Subpart; or
    3. submission of any request for reimbursement or request for arbitration filed with the board in a form other than in accordance with paragraphs (1) and (2) of this subdivision, if such requests were filed with the board on or before October 15, 1992.
    For purposes of this Subpart, the date of filing is the earlier of the date upon which the request for a computer search, together with the magnetic tape, is received by the board or the date that the HIMP-1 form is actually received by the carrier. HIMP-1 forms shall neither be filed with nor accepted by the board. No request for reimbursement may become eligible for arbitration unless it has been timely filed in accordance with the provisions of this section. Notwithstanding the foregoing, any request for reimbursement with a date of payment which is no earlier than January 1, 1988 and is more than three years from the date of the effective date of this Subpart as a final rule which has not been filed prior to such effective date shall be deemed to be filed timely if filed in accordance with the provisions of paragraphs (l) and (2) of subdivision (b) of this section no later than 60 days after the effective date of the Subpart as a final rule.

§ 325-6.3 HIMP-1 filing procedures and documentation

  1. A health insurer requesting reimbursement must serve the HIMP-l form on the carrier before such request may become eligible for arbitration. The HIMP-l form may only be served on the carrier:
    1. after the health insurer is notified of a "full match" pursuant to Subpart 325–5 of this Part, if the original request for reimbursement was filed by submission of a request for computer searches to the Board to identify claims which may be the responsibility of the carrier or was filed in accordance with section 325–6.2(b)(3) of this Subpart; or
    2. after the health insurer has obtained documentation from any source that a workers' compensation claim has or had been filed with respect to an accident for which the health insurer has made payment to a provider.
    Where the original request for reimbursement was initiated either by the submission of a magnetic tape to the board for a computer search or was filed in accordance with section 325-6.2(b)(3) of this Subpart, and the health insurer has been notified of a "partial match" pursuant to Subpart 325-5 of this Part, the health insurer may not serve the HIMP-l form on the carrier unless and until the existence of a "full match" and ANCR is determined. If the existence of a "full match" cannot be determined within two years from the effective date of this Subpart as a final rule, or within two years after the health insurer has been advised by the board of the existence of a "partial match", whichever is later, the request for reimbursement shall be deemed ineligible for arbitration pursuant to this Subpart. The time within which the existence of a "full match" and ANCR must be determined may be extended in writing by the board, upon written request by the health insurer, if the board finds that the existence of a ""full match" within the foregoing time periods could not be determined due to circumstances not within the health insurer's control. Notwithstanding the foregoing, if the existence of a "full match" has been determined within the applicable two-year period, or within such additional period as may be extended by the board in writing, but the existence of ANCR has not been determined, the request for reimbursement shall be deemed eligible for arbitration if the compensability of the workers' compensation claim was established no earlier than 90 days prior to the expiration of the applicable two-year period or any additional period as may be extended by the board or if the compensability of the claim is established subsequent to the expiration of the applicable two-year period or additional period. If the existence of a "full match" and ANCR has been determined within the foregoing time periods or within any additional time period, if extended in writing by the Board, the HIMP-1 form must be mailed by the health insurer to the carrier within six months after the effective date of this Subpart as a final rule or within six months after the health insurer has been notified of a full match and ANCR, whichever is later. In the event the existence of a "full match" has been determined within the foregoing time periods or with any additional time period, but ANCR has not been established or the existence of ANCR has not been determined, the HIMP-l form must be mailed by the health insurer to the carrier within six months after the expiration of the time period in which the existence of a "full match" and ANCR must be determined. If the health insurer timely mails the HIMP-1 form to the carrier within such six-month period, the health insurer must demonstrate that ANCR has been established and supplement its request for reimbursement in accordance with section 325-6.6(b)(1) and (2) of this Subpart.
  2. The health insurer must complete all information required on the HIMP-1 form and must submit the completed form to the carrier, together with copies of all provider bills and/or other documents which form the basis for the request for reimbursement. The provider bills and/or other documents shall include the name of the person for whom treatment was rendered, a diagnosis, the date(s) of treatment or hospitalization, an itemization of the services rendered and the charges therefore, and in the case of hospital bills, the nature of the treatment for which the claimant was hospitalized. The bills or supplemental documentation must also identify the diagnosis and/or treatment codes utilized by the health insurer to determine the amount of payment to the provider. All requests for reimbursement filed with the carrier after establishment of ANCR must contain a form C-23, C-18, C-67 or any other notice of decision issued by the Board establishing ANCR to the part of the body or for the condition for which the health insurer made payment to the provider, if such form was available to the health insurer at the time form HIMP-1 is mailed. The name of the claimant (or, in the case of death, the decedent) on the notice of decision must be the same as that of the person on whose behalf the health insurer made the payments for which reimbursement is being sought. If the HIMP-l was served on the carrier without a copy of a board notice of decision, the request for reimbursement is not eligible for arbitration until the HIMP-1 is supplemented by serving the carrier with a copy of the notice of decision in accordance with section 325-6.6(b)(1) and (2) of this Subpart. The submission of the above-referenced documents shall not in and of itself be conclusive on the issue of the health insurer's entitlement to reimbursement.
  3. Reimbursement to a health insurer by a compensation carrier under Workers' Compensation Law, §13(d), shall, except as otherwise provided in §13(d), be for an amount that is equal to the amounts actually expended by the health insurer for the medical and hospital services, provided that such amount is within the limits of the fee schedules established pursuant to Workers' Compensation Law, sections 13(a), 13-k(2), 13-1(2), and 13-m(3) or, in the case of inpatient hospital bills, the rate of payment for inpatient hospital services established pursuant to the provisions of the Public Health Law. In no event shall a carrier be required to reimburse a health insurer in an amount that exceeds the limits of the fee schedules established pursuant to Workers' Compensation Law, sections 13(a), 13-k(2), 13-1(2), and 13-m(3) or, in the case of inpatient hospital bills, in excess of the rate of payment for inpatient hospital services established pursuant to the provisions of the Public Health Law. If the amount of reimbursement claimed by the health insurer differs from the amounts expended by the health insurer and/or the amount actually paid to a provider differs from the amount set forth in the provider's bill, the health insurer must explain the basis for the difference, and what the difference represents.

§ 325-6.4 Objections to requests for reimbursement

  1. Notice of objection by a carrier to any request for reimbursement by a health insurer shall be mailed to the health insurer within 50 business days after the date the HIMP-1 form was mailed, as indicated on the HIMP-1 form, to the carrier. The basis for objection shall be specified on the HIMP-1 form or copy thereof which was sent by the health insurer to the carrier.
  2. The following issues may be interposed by a carrier as objections to requests for reimbursement, in whole or in part, by a health insurer:
    1. The compensability of the claim has not been established or the workers' compensation case has been closed without findings of accident or occupational disease, notice and causal relationship, or the compensability of the claim is the subject of a pending application for review to the board or a pending appeal to the courts, and is not subject to arbitration.
    2. The claim for reimbursement has a payment date prior to January 1, 1988 and is not subject to arbitration.
    3. Judicial proceedings have commenced prior to July 17, 1992 and the claim is not subject to arbitration.
    4. The claim has not been timely filed in accordance with paragraph (2) of subdivision (d) of section 13 of the Workers' Compensation Law as defined in the provisions of this Subpart.
    5. The treatment, services or hospitalization for which the health insurer or health benefits plan made payments was on behalf of a person other than the workers' compensation claimant, or was for a condition or injury unrelated to the workers' compensation claim, or for treatment of a part of the body for which causal relationship has not been established, except where such treatment, services or hospitalization were medically necessary and performed incidental to the treatment, services or hospitalization for the causally related condition or injury.
    6. The treatment, services or hospitalization for which the health insurer or health benefits plan made payments were not furnished on an emergency basis, and were obtained by the injured employee after authorization for such treatment, services or hospitalization was requested by the injured employee and such authorization was denied by a Workers' Compensation Law judge or other duly designated board employee.
    7. The fee was in excess of the workers' compensation fee schedule or, in the case of inpatient hospital bills, in excess of the rate of payment for inpatient hospital services established pursuant to the provisions of the Public Health Law, or the proper fee schedule amount or rate of payment for inpatient hospital services cannot be determined. In any case in which this objection is interposed, the carrier must explain why the fee was in excess of the fee schedule or rate of payment or why the proper amount cannot be determined. If this is the sole objection to the request for reimbursement, the carrier must state the amount which it believes to be the proper amount and must pay the undisputed amount to the health insurer.
    8. The bill should have been pro-rated with another physician or health provider.
    9. The carrier cannot determine from the documentation submitted whether it is responsible for payment.
    10. The carrier has previously reimbursed the health insurer or paid the health provider with respect to the claim. Proof of payment must be submitted.
  3. In addition to the objections which may be interposed pursuant to subdivision (b) of this section, a carrier may interpose any objection to a request for reimbursement, unless such objection is specifically prohibited by subdivision (d) of this section.
  4. The following issues may not be interposed as objections by a carrier to requests for reimbursement by a health insurer:
    1. The failure of a provider to seek prior authorization for treatment pursuant to section 13-a(5) of the Workers' Compensation Law and the rules and regulations promulgated thereunder.
    2. The failure of a provider to file notices and/or reports required by section 13-a(4), 13-k(3), 13-1(3) or 13-m(4) of the Workers' Compensation Law and the rules and regulations promulgated thereunder.
    3. The treatment was excessive or too frequent.
    4. The period of hospitalization was excessive and/or unnecessary.
  5. Where an objection to a request for reimbursement has been made on any of the bases set forth in subdivisions (b)(4)-(10) and (c) of this section, the issues interposed as objections shall be subject to mandatory arbitration. Where the basis for the objection is the failure to establish ANCR, no such request for reimbursement is eligible for or subject to arbitration until the compensability of the claim is established.
  6. All objections to requests for reimbursement pursuant to subdivisions (b) and (c) of this section must explain in detail the basis for the objection and must be accompanied by documentation supporting the objection. Except as provided in sections 325-6.6(c), 325-6.10(c) and 325-6.13(c) of this Subpart, no objections or supporting documents will be considered unless they have been timely mailed to the health insurer in accordance with the provisions of this Subpart.

§ 325-6.5 Eligibility for arbitration

  1. A health insurer requesting arbitration must send such request for arbitration to the dispute forum on the HIMP-1 form, in accordance with section 325-6.10 of this Subpart:
    1. within 90 calendar days after the date on which the carrier mailed its notice of objection on the HIMP-1 form to the health insurer; or
    2. if the carrier has not made payment or mailed an objection to the health insurer within 50 business days from the date that the health insurer mailed the HIMP-1 form to the carrier, within 90 days from the expiration of the period within which an objection or payment was required to be made, but in any event no earlier than 55 business days from the date on which the HIMP-1 form requesting reimbursement was initially sent by the health insurer to the carrier. Notwithstanding the foregoing, the parties may mutually agree in writing to extend the period in which the carrier must reply to a request for reimbursement.
  2. Where the health insurer or health benefits plan has filed a timely request for reimbursement, as defined in this Subpart, and has filed or supplemented its claim for reimbursement by sending HIMP-l form to the carrier, and the carrier has objected or failed to object in accordance with section 325-6.4 of this Subpart, the health insurer shall be deemed to have waived its right to arbitration if such request for arbitration is not timely mailed to the dispute forum in accordance with the provisions of subdivision (a) of this section. Notwithstanding the foregoing, where the request for reimbursement was timely filed but is not eligible for or subject to arbitration because of the inability of the health insurer to demonstrate that the compensability of the workers' compensation claim has been established or a board notice of decision was not submitted with form HIMP-1, the right to arbitration shall not be deemed to have been waived. In any such case, the health insurer may supplement its previous requests for reimbursement by furnishing the carrier with the necessary information documenting that the compensability of the claim has been established. Such supplemented information must be mailed by the health insurer to the carrier:
    1. within 90 days after the health insurer has received notice of objection from the carrier, or within 90 days after the time within which to object has expired; or
    2. within 90 days after the date of filing of the decision establishing the compensability of the claim, in any case in which the compensability of the claim is established subsequent to receipt of the notice of objection or the expiration of the time within which the carrier was required to file an objection. Upon receipt of the supplemental information demonstrating the compensability of the claim, the carrier shall be required to respond to the supplemental request for reimbursement within 50 business days in accordance with the provisions of section 325-6.4 of this Subpart. Notwithstanding the foregoing, the board may extend in writing the time within which the health insurer must demonstrate the compensability of the claim upon written request by the health insurer if the board finds that the health insurer's inability to ascertain whether ANCR had been established is due to unforeseen circumstances not within the control of the health insurer.
  3. In any case in which a request for arbitration has been submitted based on the failure of a carrier to make payment or send notice of objection to the request within 50 business days after the request for reimbursement has been made, the carrier shall be deemed to have waived any objections it may have been entitled to interpose pursuant to section 325-6.4(b) and (c) of this Subpart, except as provided in section 325-6.13(c) of this Subpart. Notwithstanding the foregoing, where the request for reimbursement has been filed with the carrier prior to August 1, 1993, an objection that the amount of reimbursement exceeds the limits of the fee schedules established pursuant to sections 13(a), 13-k(2), 13-1(2) and 13-m(3) of the Workers' Compensation Law or the fee schedules for inpatient hospital services established pursuant to the Public Health Law, or that the claim is not eligible for arbitration, pursuant to section 325-6.4(b)(1), (2) and (3) of this Subpart shall not be deemed to have been waived.

§ 325-6.6 Requests for arbitration

  1. A health insurer requesting arbitration must send such request for arbitration to the dispute forum on the HIMP-1 form, in accordance with section 325-6.10 of this Subpart:
    1. within 90 calendar days after the date on which the carrier mailed its notice of objection on the HIMP-1 form to the health insurer; or
    2. if the carrier has not made payment or mailed an objection to the health insurer within 50 business days from the date that the health insurer mailed the HIMP-1 form to the carrier, within 90 days from the expiration of the period within which an objection or payment was required to be made, but in any event no earlier than 55 business days from the date on which the HIMP-1 form requesting reimbursement was initially sent by the health insurer to the carrier. Notwithstanding the foregoing, the parties may mutually agree in writing to extend the period in which the carrier must reply to a request for reimbursement.
  2. Where the health insurer or health benefits plan has filed a timely request for reimbursement, as defined in this Subpart, and has filed or supplemented its claim for reimbursement by sending HIMP-1 form to the carrier, and the carrier has objected or failed to object in accordance with section 325-6.4 of this Subpart, the health insurer shall be deemed to have waived its right to arbitration if such request for arbitration is not timely mailed to the dispute forum in accordance with the provisions of subdivision (a) of this section. Notwithstanding the foregoing, where the request for reimbursement was timely filed but is not eligible for or subject to arbitration because of the inability of the health insurer to demonstrate that the compensability of the workers' compensation claim has been established or a board notice of decision was not submitted with form HIMP-1, the right to arbitration shall not be deemed to have been waived. In any such case, the health insurer may supplement its previous requests for reimbursement by furnishing the carrier with the necessary information documenting that the compensability of the claim has been established. Such supplemented information must be mailed by the health insurer to the carrier:
    1. within 90 days after the health insurer has received notice of objection from the carrier, or within 90 days after the time within which to object has expired; or
    2. within 90 days after the date of filing of the decision establishing the compensability of the claim, in any case in which the compensability of the claim is established subsequent to receipt of the notice of objection or the expiration of the time within which the carrier was required to file an objection. Upon receipt of the supplemental information demonstrating the compensability of the claim, the carrier shall be required to respond to the supplemental request for reimbursement within 50 business days in accordance with the provisions of section 325-6.4 of this Subpart. Notwithstanding the foregoing, the board may extend in writing the time within which the health insurer must demonstrate the compensability of the claim upon written request by the health insurer if the board finds that the health insurer's inability to ascertain whether ANCR had been established is due to unforeseen circumstances not within the control of the health insurer.
  3. In any case in which a request for arbitration has been submitted based on the failure of a carrier to make payment or send notice of objection to the request within 50 business days after the request for reimbursement has been made, the carrier shall be deemed to have waived any objections it may have been entitled to interpose pursuant to section 325-6.4(b) and (c) of this Subpart, except as provided in section 325-6.13(c) of this Subpart. Notwithstanding the foregoing, where the request for reimbursement has been filed with the carrier prior to August 1, 1993, an objection that the amount of reimbursement exceeds the limits of the fee schedules established pursuant to sections 13(a), 13-k(2), 13-l(2) and 13-m(3) of the Workers' Compensation Law or the fee schedules for inpatient hospital services established pursuant to the Public Health Law, or that the claim is not eligible for arbitration, pursuant to section 325-6.4(b)(1), (2) and (3) of this Subpart shall not be deemed to have been waived.

§ 325-6.7 Qualifications of arbitrators

  1. The chair shall appoint an advisory committee composed of four members who will review the qualifications of applicants for the position of arbitrator of disputed requests for reimbursement and review their performance. The advisory committee shall make recommendations to the chair pertaining to the appointment and dismissal of arbitrators. The committee shall consist of one representative each of the AFL-CIO, the Business Council of New York, the State Insurance Fund, and the board.
  2. An arbitrator shall have a basic knowledge of the Workers' Compensation Law which will qualify such arbitrator to resolve issues involved in reimbursement disputes. Documentation of such knowledge and related experience shall be submitted to the advisory committee.
  3. All arbitrators shall be appointed by, and serve at the pleasure of, the chair. An arbitrator candidate shall disclose to the chair any circumstance which is likely to create an appearance of bias or which might disqualify such a person as an arbitrator, and the chair shall determine whether the candidate should be disqualified. The chair shall forward the names of all arbitrators to the dispute forum, and promptly inform the dispute forum of all additions to, and deletions from, the panel of arbitrators.
  4. Any arbitrator appointed by the chair shall be subject to disqualification with respect to a particular case for the reasons specified in section 325-6.8 of this Subpart. The advisory committee shall establish any additional qualifications for appointment as an arbitrator as it may deem necessary.

§ 325-6.8 Appointment of arbitrators

The dispute forum shall select from the panel of arbitrators, on a rotational basis, an arbitrator who will hear the case and shall submit the name of the arbitrator to each party to the arbitration. Any person appointed as an arbitrator shall disclose to the dispute forum any circumstance likely to affect impartiality, including any bias, financial and/or personal interest in an arbitration. Upon receipt of such information from the arbitrator or another source, the dispute forum shall communicate the information to the parties, and if it deems appropriate to do so, to the arbitrator and other interested parties. If a party objects to the appointment of an arbitrator, the specific grounds for such objection shall be submitted in writing to the dispute forum, which shall determine within 15 calendar days after receipt of the challenge whether the arbitrator shall be disqualified. The dispute forum shall determine whether the arbitrator shall be disqualified and shall notify the parties of its decision, which shall be final and binding. In the event an arbitrator shall resign, be disqualified or be otherwise unable to perform his or her duties, the dispute forum shall appoint another arbitrator.

§ 325-6.9 Oaths

All arbitrators shall be required to take an annual oath of office. Arbitrators shall require all witnesses to testify under oath or affirm that their statements are true under penalty of perjury.

§ 325-6.10 Initiation of processing

  1. The health insurer shall initiate the request for arbitration by forwarding the completed request for arbitration to the carrier and two copies of the completed HIMP–1 form together with two copies of all documents previously submitted to the carrier, proof of service of all documents upon the carrier and the prescribed filing fee to the dispute forum. In the event that the carrier has failed to mail a notice of objection to the request for reimbursement within 50 business days in accordance with section 325–6.4 of this Subpart, the health insurer shall state in the request for arbitration that no objections have been received and shall provide proof of the date of service of the request for reimbursement with the carrier. Where the request for reimbursement is initiated by a request for computer matching to the Board on or after the effective date of this Subpart as a final rule, the health insurer shall submit proof of service of both the request for computer matching as well as proof of service of the HIMP–1 form.
  2. Upon receipt of the completed request for arbitration, the dispute forum shall acknowledge receipt of the request for arbitration by notifying both parties by regular mail. Any request for arbitration which is not accompanied by the completed form, proof(s) of service and/or the required fee shall not be processed and shall be returned to the health insurer.
  3. Within 10 business days after receipt of acknowledgment of the completed request for arbitration from the dispute forum, the carrier shall submit to the dispute forum two copies of all documents supporting its objections to the requests for reimbursement, together with proof of timely filing of such documents with the health insurer. Except as provided in section 325-6.13(c) of this Subpart, such documents will not be considered by the arbitrator, unless the carrier has previously filed a timely notice of objection and such supporting documents with the health insurer in accordance with section 325-6.4 of this Subpart. The carrier shall place the dispute forum's case identification number on each document. Notwithstanding the foregoing, where the HIMP-1 form has been mailed to the carrier prior to August 1, 1993, submission of documents by the carrier supporting their objections to requests for reimbursement will be considered as timely submitted if within 10 business days after receipt of its copy of the completed request for arbitration from the health insurer the carrier submits such documents to the health insurer and files with the dispute forum two copies of such documents together with proof of service upon the health insurer.

§ 325-6.11 Time and place of arbitration; notification

  1. Unless either party requests an oral hearing, all hearings shall be desk arbitrations based on documents alone.
  2. A health insurer or health benefits plan requesting an oral hearing must make such request together with its submission of its request for arbitration. A carrier may make a request for an oral hearing within 10 business days after receipt of its copy of the request for arbitration. Such request must be made in writing to the dispute forum, and a copy of such request must be simultaneously mailed to the health insurer. The party requesting an oral hearing shall designate the locale of such hearing, which shall be the city of the board district office serving the location where the underlying compensability of the compensation claim giving rise to the request for reimbursement was established.
  3. Desk arbitrations shall be conducted at one of the offices of the board or any location designated by the chair for such purpose. The dispute forum shall determine the date, time and place of hearing for desk arbitrations.
  4. The arbitrator shall set the date and time of oral hearing which shall be at one of the offices of the board or dispute forum and in the locale designated pursuant to subdivision (b) of this section, unless the arbitrators and the parties shall mutually agree upon a different location. The dispute forum will notify the parties at least 10 business days in advance of the date, time and place of any oral hearing. Notification may be made by mail, facsimile transmission, telex, telegram or any other written form of electronic communication.

§ 325-6.12 Withdrawal of arbitration requests

The parties may, by mutual agreement, withdraw the request for arbitration on a form prescribed by the dispute forum for that purpose. Such form must be signed by the parties and filed with the dispute forum. If requested by the parties, their agreement to withdraw may be incorporated in an arbitration award. Additionally, the party requesting arbitration may unilaterally withdraw a request for arbitration by filing such request for withdrawal with the dispute forum and sending a copy to the other party. Where the request for arbitration has been withdrawn, fees paid to the dispute forum shall not be refundable, except as provided in section 325-6.15(b) of this Subpart. No request for arbitration may be unilaterally withdrawn unless the withdrawing party has reimbursed the other party for any non-refundable fee which such other party has paid to the dispute forum.

§ 325-6.13 Hearing of cases

  1. The arbitrator shall determine initially whether the claim is eligible for or subject to mandatory arbitration. If the arbitrator determines that the claim is not eligible for any of the reasons set forth in section 325-6.5(b) or (c) of this Subpart, the claim shall not be arbitrated and the arbitrator shall notify the parties in writing. Any party aggrieved by the arbitrator's determination may, within 30 days after notification by the arbitrator, file with the dispute forum, upon notice to the other party, a request that the arbitrator issue a decision pursuant to section 325-6.14 of this Subpart denying the claim on the basis that the claim is not eligible for or subject to mandatory arbitration. Such decision may be appealed pursuant to section 325-6.16 of this Subpart.
  2. The arbitrator shall not be bound by common law or statutory rules of evidence or by technical or formal rules of procedure but may make such investigation or inquiry and conduct the hearing in such manner as he or she deems proper and necessary, and shall have the power to issue subpoenas, in accordance with section 7505 of the Civil Practice Law and Rules. In any oral hearing, the health insurer may present its case, call witnesses and present proofs, and submit to questions thereon. The defending carrier may present its defense, call its witnesses, present its proofs and submit to questions thereon. The arbitrator may, in the event of nonappearance, decide the issue on the basis of the evidence before it. Either party may be represented by an attorney.
  3. Except as provided in sections 325-6.6(c) and 325-6.10(c) of this Subpart, the arbitrator will only consider those objections to requests for reimbursement which have been timely filed with the health insurer in accordance with section 325-6.4 of this Subpart, and documents supporting objections to requests for reimbursement which have been timely filed with the health insurer in accordance with section 325-6.4(a) and (f) of this Subpart or supporting the request for reimbursement, which have been timely mailed to the carrier in accordance with section 325-6.2 of this Subpart. Where the HIMP-1 form is filed on or after August 1, 1993, any party wishing to file new or additional objections or documents based solely on newly discovered evidence after the expiration of the time for filing objections or documents must file such objections or documents with the dispute forum no later than 10 business days prior to the scheduled date of decision, in the case of desk hearings, or no later than 10 business days prior to the scheduled date of an oral hearing. The new or additional objections or documents must be accompanied by an affidavit substantiating why such objections or documentation could not have been made or discovered and filed within the prescribed time period, together with proof of service of all additional objections or documents, including the supporting affidavit, on the other party. The arbitrator may, in his or her sole discretion, consent in writing to the submission of new or additional objections or documentation and consider such new or additional objections or documents when making his or her decision if he or she determines that special circumstances exist whereby such evidence could not have been previously discovered and consideration of the new or additional objections or documentation in the interests of justice is warranted. Where payment is made by the carrier after the request for arbitration has been filed, the carrier must submit proof of payment. If it is determined by the arbitrator that full payment has been made but such payment was not timely, the arbitrator must award the health insurer any filing fees paid by it, in accordance with this section.
  4. A stenographic record of oral hearings shall not be required. Any party requesting such a record shall inform the other party and the arbitrator of such intent, shall make the necessary arrangements and pay the cost thereof directly to the person or agency making such record. The arbitrator and any other party or parties to the arbitration shall be entitled to view the record and shall be entitled to a copy of such record upon payment of the cost of a copy of such record.
  5. The arbitrator may postpone or adjourn any hearing upon request of a party or upon the arbitrator's own motion. Each party may cause one adjournment without the payment of an adjournment fee if the adjournment request is received by the dispute forum at least two business days prior to the scheduled arbitration. There shall be an adjournment fee of $ 50 payable to the dispute forum by the party requesting any subsequent adjournment if such request is received by the dispute forum at least two business days prior to the scheduled arbitration. An adjournment fee of $ 100 shall be payable to the dispute forum by the party causing the adjournment within two business days or less prior to the scheduled hearing. Such fees shall be used to defray the cost of administration of the dispute forum.

§ 325-6.14 Decisions of the arbitrator; awards; interest

  1. The arbitrator shall make a decision in writing no later than 30 days after completion of a hearing. The decision shall contain a dollar amount of an award or a denial of the claim, and shall specify the basis of the decision on the form prescribed by the dispute forum for such purpose. The decision may include any stipulation made by the parties, including stipulations as to payment of fees. The decision shall be delivered to each party personally or by mail.
  2. In the event the arbitrator's decision is in favor of the health insurer in the full amount requested, the amount of the award shall be increased by the amount of any filing fee, or any additional fee paid by the health insurer except attorney's fees, for oral hearings. In the event the claim for reimbursement is denied in full, the arbitrator shall make an award in favor of the carrier for any filing fees or additional fees, except attorney's fees, paid by the carrier. In all other cases, the arbitrator shall, in his or her discretion, determine whether such fees shall be allocated and the manner of such allocation provided, however, that in all cases in which the arbitrator's decision is based in whole or in part upon objections or documents received and accepted by the arbitrator as newly-discovered evidence pursuant to section 325-6.13(c) of this Subpart, and is entirely or partly in favor of the party which submitted the objections or documents untimely, any filing fees shall be chargeable to such party in whole or in part. In any such case the arbitrator, when allocating such fee, shall consider the extent to which the other party may have been prejudiced by the prevailing party's failure to submit the objections or documentation in a timely manner. If payment is made to the health insurer or health benefits plan after the time within which the carrier was required to object or making payments has expired, and the carrier submits proof of payment after the health insurer has filed a request for arbitration, the arbitrator shall make an award to the health insurer for any filing fees paid by it.
  3. Awards shall be paid to the prevailing party no later than 30 calendar days after service of the decision upon the parties. Any awards remaining unpaid after said 30 day period shall draw simple interest from 30 days after the making of the award at the rate provided in section 5004 of the Civil Practice Law and Rules.

§ 325-6.15 Fee structure

  1. The health insurer shall, together with its request for reimbursement, submit a non-refundable filing fee in the amount of $150 per request, for desk arbitrations, the arbitrator shall receive a fee of $40 per arbitration, payable by the dispute forum from the filing fees received by it.
  2. In the event either party shall demand an oral hearing, a fee in the amount of $ 475, of which $ 250 shall be paid to the arbitrator, shall be paid to the dispute forum together with such demand. The party requesting the oral hearing shall pay an additional sum of $ 250 as the arbitrator's fee for any additional day of oral hearing. In the event the request for oral hearing is withdrawn prior to the commencement of the oral hearing, the sum of $ 250 representing the arbitrator's fee shall be refunded by the dispute forum to the party requesting such hearing.
  3. The fees payable pursuant to the provisions of this section shall apply to all requests for arbitration properly submitted to the dispute forum no later than 90 days after the effective date of this Subpart as a final rule. Subsequent to that date, the fees shall be at such rate as may be established and promulgated by the chair pursuant to the provisions of this Subpart.

§ 325-6.16 Enforcement and appeals of decisions

Any decisions of an arbitrator made pursuant to the provisions of this Subpart may be enforced, vacated or modified in accordance with the applicable provisions of sections 7509, 7510, 7511 and 7514 of the Civil Practice Law and Rules. No other provisions of Article 75 of the Civil Practice Law and Rules, except as may be otherwise provided in this Subpart, shall be applicable to arbitration pursuant to this Subpart. The arbitrator, dispute forum and the board shall not be made parties to a court proceeding relating to an arbitration award unless their presence as a party is pertinent to any issues raised in the litigation. The participation of a party in such an arbitration proceeding shall be a waiver of any claim against an arbitrator or the dispute forum for any act or omission in connection with any arbitration conducted under these rules.

§ 325-6.17 Dispute forum rules

All parties subject to the provisions of this Subpart shall be subject to any rules promulgated by the dispute forum with respect to its own internal procedures regarding the administration of disputed requests for reimbursement, to the extent that such rules are not inconsistent with this Subpart.