In some instances, a health insurer may make a payment for one of its members, only for the member's treatment to later be found to fall under the purview of a workers' compensation claim. In such cases, the Health Insurance Matching Program (HIMP) provides a mechanism for health insurers to seek reimbursement from employers and workers' compensation insurers.
HIMP is codified at WCL §§ 13(d) and 13(h). The rules governing HIMP are located in 12 NYCRR §§ 325-5 and -6.
Seeking Reimbursement Under HIMP
In order to be entitled to reimbursement under HIMP, the health insurer must follow a very particular procedure. First, within three years of making the payment on behalf of the member, the health insurer should make a HIMP search request in electronic form to the NYS Office of Information Technology Services (ITS) at Himptech@wcb.ny.gov.1 The health insurer should provide information regarding payments on behalf of their members, including name, Social Security number, gender, date of birth, and treatment date. If the health insurer does not have all of this information, it may submit that information which it does have.
ITS will then notify the health insurer of those members for which there is a full or partial match, depending on which information fields are identical in both the health insurer's and the Board's records.
In the event of a "full match," the health insurer will be eligible to request reimbursement from the workers' compensation insurer. To be entitled to such reimbursement, a health insurer requesting reimbursement must serve a New York State Workers' Compensation Board Health Insurance Matching Program Form (Form HIMP-1) on the workers' compensation insurer. The Form HIMP-1 may only be served on the workers' compensation insurer after the health insurer is notified of a "full match" by the Board.
In the event of a "partial match," the health insurer is not eligible for reimbursement, but possibly may become so at a later point if the claim later becomes established. The health insurer may continue to resubmit the data match through ITS to see if a "full match" ever arises. However, if the data submission which leads to a "full match" was not submitted to the Board within three years of the health insurer having made the payment on behalf of the member, even if previous submissions resulted in a "partial match," the request for reimbursement may no longer be timely.
1 There is a fee for this process; please refer to 12 NYCRR § 325-5.6 for the delineation of the relevant fees.
Health insurers have the option to contract with a HIMP agent, aka a "HIMP vendor," to conduct HIMP searches on their behalf.
To be eligible to conduct such searches, a HIMP agent must execute written agreements, in a format prescribed by the Chair, between the HIMP agent, the health insurer, and the Board, and file such agreements with the Board. To obtain a copy of the required forms to execute such agreements, please contact the Office of General Counsel at OfficeofGeneralCounsel@wcb.ny.gov.
Once a HIMP agent has signed the necessary agreements, the HIMP agent may submit requests to ITS in the same manner as a health insurer. The HIMP agent must abide by the terms of the agreements, as well as all regulations and policies applicable to health insurers. The failure to comply is grounds for termination of an individual or entity's status as a HIMP agent and to preclude its participation the HIMP program.
Disputing a Request for Reimbursement
If the workers' compensation insurer wishes to object to the HIMP reimbursement request, it may indicate its objection(s) directly on the Form HIMP-1 if sent to it by the health insurer. The objecting insurer should then return the form with the noted objections to the health insurer.
If, despite the workers' compensation insurer's objections, the health insurer continues to feel it is entitled to reimbursement, the health insurer may seek arbitration. HIMP disputes are handled by the American Arbitration Association (AAA) and thus fall outside of the jurisdiction of the Board. Please see the AAA's HIMP webpage for more information on this process.
Annual Reporting Requirements
Each health insurer and HIMP agent partaking in the HIMP program must also submit annual reports to the Board informing the Board of the number of reimbursement requests, HIMP-1 forms submitted, and arbitration requests it made in the preceding year, as well as names of the health care providers for which it discovered duplicate payments made by the health insurer and the number of such duplicate payments made in that year.