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Text of Amendment of 12 NYCRR 300.22, 300.26, 300.29, 300.33,
300.37, 312.2, 312.5, 327.3 and 403.1 (To Conform to eClaims)


Subparagraph (4) of subdivision (f) of section 300.22 of Title 12 of the NYCRR is amended as follows:

4. Reporting of other types of benefits. Upon submission of a subsequent report of injury required by subparagraphs (1) [or], (2)[,] or (3), the carrier, Special Fund, or TPA shall be responsible for reporting the total amount and type of payments made in connection with the claim, including: (i) all penalties paid to the claimant or New York State; (ii) all medical expenses including payments to physicians, chiropractors, physical therapists or other medical providers, payments to hospitals, payments for pharmaceuticals, payments for dental expenses, payments for durable medical goods, payments for medical and travel expenses reimbursed to the claimant, any other medical expenses; (iii) attorney fees or other legal fees; (iv) interest paid. Such reports shall be filed electronically in the format prescribed by the chair and shall contain the data elements prescribed by the chair.

Section 300.26 of Title 12 of the NYCRR is amended as follows:

§ 300.26 Information to be furnished with each payment of compensation

The employer or carrier paying compensation to a claimant shall specify with each payment the period for which such payment is made, and the rate[.] , and shall notify the Board of such payment and the period for such payment when prescribed in subdivision (f) of section 300.22 of this Part.

Section 300.29 of Title 12 of the NYCRR is amended as follows:

§ 300.29 Modification of distribution of payment in compliance with income execution or income deduction

Any party liable for the payment of a compensation award may modify the distribution of such payment without the necessity of a Workers' Compensation Law Judge hearing or notice of decision where such modification is made in order to comply with an income execution or income deduction issued pursuant to an order of support as defined in CPLR 5241 and CPLR 5242 which has been served upon said party. Where said party is otherwise required to [file a form C-8/8.6]file electronically a notice of payment modification pursuant to section 300.22, [a form C-8/8.6]the notice of payment modification and a copy of the income execution or income deduction shall be [filed with]submitted to the Chair with [proof of mailing of] copies thereof upon the claimant and his or her legal representative (if any). Any modification of payment made in compliance with an income execution or income deduction order for support enforcement issued pursuant to an order of support as defined in CPLR 5241 and CPLR 5242 shall not be grounds for imposition of a penalty under the Workers' Compensation Law, so long as the monies paid in compliance with the income execution or income deduction order are limited to those monies which would have been paid to the claimant, after payment of any liens for attorney or licensed representative fees, or for prior payment made by a disability benefits carrier, or for advance payments of compensation by an employer.

Subdivision (b) of section 300.33 of Title 12 of the NYCRR, is amended as follows:

(b) All cases in which a notice of controversy and a medical report referencing an injury are [filed]submitted shall be scheduled for a pre-hearing conference to be held as soon as practicable, but in no event more than 30 calendar days after receipt by the board of the notice of controversy and a medical report referencing an injury. Cases with outstanding issues, which cannot be processed through conciliation or administrative determination, shall be referred to a pre-hearing conference when necessary to complete any discovery.

Subdivision (d) of section 300.33 of Title 12 of the NYCRR, is amended as follows:

(d) All represented parties must file a pre-hearing conference statement in accordance with section 300.38(f) of this Part.

Subparagraph (1) of subdivision (f) of section 300.33 of Title 12 of the NYCRR, is amended as follows:

(f) If the claimant has not retained a legal representative on or before the date of the pre-hearing conference, the following provisions shall apply:

Subparagraph (4) of subdivision (f) of section 300.33 of Title 12 of the NYCRR, is amended as follows:

(4) Ten days before the pre-hearing conference, the insurance carrier shall file with the board a pre-hearing conference statement, on a form prescribed by the chair, noting all of the specific issues in dispute. The employer's or carrier's statement shall be accompanied by the carrier or employer's first report of injury, [(C-2)]and any medical reports, from a treating health provider(s) or consultants, which the employer or carrier has in its possession.

Section 300.37 of Title 12 of the NYCRR is amended as follows:

§ 300.37 Case file creation and indexing of claims that may be controverted

(a) Case File. Upon receiving any document or notice regarding a claim or potential claim for workers' compensation benefits for which a case number has not been assigned and a case file has not been created, the Board shall assign a unique case number and create a case file. The assignment of a case number and creation of a case file is not the indexing of a claim for purposes of filing a notice of controversy in accordance with paragraph (b) of subdivision (2) of section 25 of the Workers' Compensation Law. The Board shall assign the case number and create the case file within five business days of receipt of said document for which a case file does not exist. Nothing in this section changes existing law with respect to the filing of a claim for purposes of the limitations period set forth in Workers' Compensation Law section 28.

(b) Indexing.

(c) When claim is not indexed.

(d) Provisions applicable to all claims that have been or may be controverted.

Section 312.2 of Title 12 of the NYCRR is amended as follows:

§ 312.2 Referral to conciliation processing

Within 30 days of carrier's response to notice of indexing., all cases where the expected duration of benefits is 52 weeks or less shall be referred for conciliation processing, except if a case is suitable for motion calendar or administrative determination processing. If a case is initially controverted [(C-7 filed)], the case will be processed for a pre-hearing conference under subdivision 2-a of section 25 of the Workers' Compensation Law.

Subdivision (h) of section 312.5 of Title 12 of the NYCRR is amended as follows:

(h) The carrier is to [file form C-8/8.6]submit the report of payments as required by section 300.22 showing payments have been made. [Form C-8/8.6 in conciliation cases is to be filed within the time frame enumerated in section 25 of the Workers’ Compensation Law.]

Section 327.3 of Title 1 2of the NYCRR is amended as follows:

§ 327.3 Notice of carrier's objections to bills and hospital's request for arbitration [of bills for services rendered on or after October 1, 1994]

(a)

(b) Upon receipt of a timely written notification of the carrier's explanation for non-payment in accordance with subdivision (a) of this section, the hospital may request arbitration by notifying the chair in accordance with the following:

(c) The hospital's failure to submit a bill to the carrier within 120 days from the last day of the month in which services were rendered shall be deemed a waiver of the right to arbitrate the bill; provided, however, that upon application of the hospital, the chair may for good cause shown excuse the hospital for delay in submitting such bill to the carrier, and schedule the bill for arbitration.

Section 403.1 of Title 12 of the NYCRR is amended as follows:

§ 403.1 Priority processing of controverted claims for benefits by volunteer firefighters for death or disability due to disease or malfunction of the heart or of one or more coronary arteries The following procedures shall apply to all controverted claims for benefits for the death or disability of a volunteer firefighter due to disease or malfunction of the heart or of one or more coronary arteries:

(a) All claims for benefits shall be filed with the chair on a form prescribed by the chair, completed with such information as may be required therein. After receipt of the prescribed form, a notice of indexing shall be mailed on an expedited basis.

(b) (1) Upon receipt of a notice of controversy, the board shall expedite the processing of the claim by scheduling any pre-hearing conference as may be required by the Workers' Compensation Law on a priority basis. Any proceedings required before a Workers' Compensation Law judge subsequent to any pre-hearing conference shall also be scheduled on a priority basis. If the carrier has not timely[filed form C-6, C-7 or C-9] submitted a notice of initial action to the Board pursuant to section 25 of the Workers' Compensation Law and section 300.22 of this Title, a priority hearing shall be set.(2) When a hearing is set for testimony on any controverted issues, all witnesses shall be scheduled for testimony on that date.

(c) All controverted claims shall be entitled to priority processing as required by section 61 of the Volunteer Firefighters' Benefit Law and shall be processed in accordance with this section, provided, however, that the 90-day period for expedited determination of a claim pursuant to subdivision 2 of section 61 of the Volunteer Firefighters' Benefit Law shall commence from and be conditioned upon the board's receipt of a completed claim. For purposes of this section, a completed claim in a controverted case shall include a completed claim form as set forth in subdivision (a) of this section, prima facie medical evidence and a notice of controversy[(form C-7) filed with] submitted to the chair.

(d) Notwithstanding any other provisions of this Title to the contrary, an employer or carrier initially controverting a claim on the issue of whether the claimant has a causally related disability due to disease or malfunction of the heart or of one or more coronary arteries, and desiring to have the claimant examined by its consultant, shall have the claimant examined either prior to the first scheduled pre-hearing conference or within 30 days after receipt of a prima facie medical report stating that claimant has a causally related disability due to disease or malfunction of the heart or of one or more coronary arteries, whichever is later. In the event the carrier or employer fails to have the claimant timely examined in accordance with the foregoing, the carrier or employer shall not be granted an adjournment by the Workers' Compensation Law judge for the purpose of obtaining a consultant's report with respect to the issue of causally related disability as set forth in such prima facie medical report, unless it is determined that the failure of the carrier to have the claimant examined was due to circumstances which were solely within the control of the claimant.


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