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Glossary of WCB Terms

 

Laws Regarding HIMP


WCL § 13(d)

  1. In the event that an insurer or health benefits plan makes payments for medical and/or hospital services for or on behalf of an injured employee they shall be entitled to be reimbursed for such payments by the carrier or employer within the limits of the medical and hospital fee schedules if the board determines that the claim is compensable. For the purposes of this section, an insurer or health benefits plan includes a medical expense indemnity corporation, a health or hospital service corporation, a commercial insurance company licensed to write accident and health insurance in the state of New York, a health maintenance organization operating in accordance with article forty-three of the insurance law or article forty-four of the public health law, or a self-insured or self-funded health care benefits plan operated by, or on behalf of, any business, municipality or other entity (including an employee welfare fund as defined in article forty-four of the insurance law or any other union trust fund or union health benefits plan). Notwithstanding any other provision of law, in no event shall the carrier or employer be required to reimburse the insurer or health benefits plan in an amount greater than the amount paid for medical and hospital services for or on behalf of the injured employer by such corporation or company; provided, however, if the carrier or employer does not reimburse the insurer or health benefits plan within thirty days after the board determines that the claim is compensable, the carrier or employer shall reimburse the insurer or health benefits plan at the amount the carrier or employer would be obligated to reimburse the hospital or other provider of medical services if the carrier or employer made payment directly to the provider of medical and/or hospital services pursuant to this chapter (or, in the case of inpatient hospital services, pursuant to paragraphs (b) and (b-1) of subdivision one of section twenty-eight hundred seven-c of the public health law). Upon reimbursement to the insurer or health benefits plan pursuant to this subdivision, the carrier or employer shall be relieved of liability for the medical and/or hospital services for which payment has been made by the insurer or health benefits plan.
  2. An insurer or health benefits plan entitled to reimbursement pursuant to paragraph one of this subdivision shall receive copies of the hearing and decision notices and shall develop with the carrier or employer its own mechanisms and standard operating procedures for payment of undisputed claims for reimbursement. In cases of disputed claims for reimbursement that are filed with the board within three years of the date of payment for services rendered by the health care provider or within ninety days of the effective date of a chapter of the laws of nineteen hundred ninety-two, entitled "AN ACT to amend the workers' compensation law, in relation to reimbursement of insurers and health benefit plans", whichever is later, the sole remedy of the insurer or health benefit plan to recover on a claim arising pursuant to this subdivision shall be the submission of the controversy to mandatory arbitration or other alternative dispute resolution procedures as defined by rules and regulations promulgated by the chair in accordance with subdivision (h) of this section.

WCL § 13(h) (h)

  1. The chair shall require the performance of computer searches to identify injured employees who, with respect to the same injury or illness, have filed claims under the provisions of this chapter and made claims to, or on their behalf with, a payor of medical payments eligible for reimbursement pursuant to this section. Such searches shall be done at least quarterly upon request of payors and upon submission to the board of computer tapes containing the information the chair shall need to identify injured employees who file dual claims under this section. At least quarterly, the chair shall identify injured employees who have filed dual claims by social security number and workers' compensation board number and shall notify the payor of such results.
  2. Such payor shall use the information of dual filings solely for the purpose of reimbursement from the carrier or employer. The chair, upon a finding that such entity has used the information for purposes other than reimbursement from the carrier or employer, may, after hearing, impose a penalty of not more than ten thousand dollars and may prohibit such entity from receiving information under this subdivision for up to three years.
  3. The chair shall adopt rules and regulations to carry out the provisions of this section, which rules and regulations shall provide for alternative dispute resolution procedures for settlement of disputed claims for reimbursement under subdivision (d) of this section including but not limited to referral and submission of disputed claims to mandatory arbitration with private arbitration associations. Such rules and regulations may provide for a reasonable fee to be charged to payors for computer searches. Claims for computer searches submitted to the board prior to March thirty-first, nineteen hundred ninety-two, may be submitted with a payment date on or after April first, nineteen hundred eighty-eight. Claims for reimbursement submitted after March thirty-first, nineteen hundred ninety-two, shall have a payment date that is no later than three years prior to the date of submission of the claim for matching purposes to the board. If disputed, these claims shall be resolved through the dispute resolution procedures set forth in this section. Upon resolution of the reimbursement dispute in accordance with this section, the amount paid to the prevailing party shall be increased by the amount of any fee paid to the arbitrator or incurred by reason of any other alternate dispute resolution procedure.