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eClaims Process for Section 21-a and Claims Paid Without Liability

eClaims

When an insurer is unsure of its liability with respect to a workers' compensation claim, the insurer may use New York State Workers' Compensation Law (NYS WCL) §21-a to extend its time to investigate the claim. NYS WCL-§21-a permits the insurer to take up to one year (365 days) to determine whether it will accept or deny the claim when:

Process for dates of accident on or after January 1, 2027

Whenever payment of medical or indemnity benefits is made in a claim insurers are required to indicate whether benefits are being paid with liability for indemnity and medical (L) or paid without liability for indemnity and medical (W) under NYS WCL §21-a. When the insurer selects an Agreement to Compensate Code (ATC) of L or W, the received date of the first instance of W being included on the FROI/SROI begins the 365 day §21-a period.

In general, whenever the first medical payment or indemnity payment of compensation has been made on a claim, the insurer must indicate on its first FROI or SROI (if an ATC code was not included on a previously submitted FROI) filing, that the medical or indemnity payment is made with liability (L) or without liability (W). When a FROI/SROI is filed with a W, the servable form of the FROI/SROIs will contain the required notice from the Board to the claimant. The case will be identified as subject to NYS WCL §21-a and no further notice will be sent by the Board. The eClaims requirement table lists the FROI/SROI filings that must indicate W or L when filed.

Filing using the Agreement to Compensate Code W

To invoke NYS WCL §21-a, the insurer must use the ATC code of W on the first FROI/SROI that is filed where an ATC is included. 365 days (one year) will begin from the received date of the first instance of W being included on the FROI/SROI.

Ending WCL §21-a status

There are three ways for an insurer to properly end a case's NYS WCL §21-a status:

  1. Accept the case: An L filing after the first FROI/SROI with a W indicates that the insurer has accepted the case and the case will no longer be marked as subject to NYS WCL §21-a.
  2. Controvert the case: An insurer that wishes to controvert the case after a W filing must file a SROI-SX with a Full Denial Reason Code (DN0198) of SJ before filing the SROI-04. Filing the SROI-SJ satisfies the insurer's obligation under NYS WCL §21-a. Failure to timely or properly follow this procedure may result in a case being deemed accepted pursuant to NYS WCL §21-a.
  3. Accept the case by allowing one year to pass: When the insurer's initial FROI/SROI has a W designation, and 365 days have passed from the received date of the first instance of W being included on the FROI/SROI, and the insurer has not properly controverted the case, the case is deemed accepted. The insurer must file a SROI-02 with the L designation.

Process for dates of accident on or after January 1, 2019, but prior to January 1, 2027

Insurers are required to indicate whether benefits are being paid with liability (L) or paid without liability (W) under NYS WCL §21-a. When the insurer selects an Agreement to Compensate Code of L on a First Report of Injury (FROI) or Subsequent Report of Injury (SROI), the insurer is accepting the claim. When the insurer selects an Agreement to Compensate Code of W code on a FROI or SROI, the insurer paying without prejudice pursuant to NYS WCL §21-a.

In general, whenever the first indemnity payment of compensation has been made on a claim, the insurer must indicate on its first SROI filing, that the payment is made with (L) or without (W) liability. When a SROI is filed with a W, the servable form will contain the required notice from the Board to the claimant. The case will be identified as subject to NYS WCL §21-a and no further notice will be sent by the Board. The eClaims requirement table lists the SROIs that must indicate W or L when filed.

Important: The L Agreement to Compensate Code indicates acceptance of the claim. When a SROI is filed with an L, the Board will mark this case as accepted for the body part(s) identified in the FROI.

Filing using the Agreement to Compensate Code W

To invoke NYS WCL §21-a, the insurer must use the W code on the first SROI that is filed.

Ending WCL §21-a status

There are three ways for an insurer to properly end a case's NYS WCL §21-a status:

  1. Accept the case: An L filing after the first SROI with a W, indicates that the insurer has accepted the case and the case will no longer be marked as subject to NYS WCL §21-a.
  2. Controvert the case: An insurer that wishes to controvert the case after a W filing, must file a SROI-SX with a Full Denial Reason Code (DN0198) of SJ before filing the SROI-04. Filing the SROI-SJ satisfies the insurer's obligation under NYS WCL §21-a(3). Failure to timely or properly follow this procedure may result in a case being deemed accepted pursuant to NYS WCL §21-a(4).
  3. Accept the case by allowing one year to pass: When the insurer's initial SROI has a W designation, and 365 days have passed from the first benefit payment issue date, and the insurer has not properly controverted the case, the case is deemed accepted. The insurer must file a SROI-02 with the L designation.

To avoid losing 21-a status

If any of the following occur, the insurer may lose their rights to continue payments per NYS WCL §21-a, as the case may be established:

  1. Object to payments of a medical bill (using Notice of Objection to a Payment of a Bill for Treatment Provided (Form C-8.1B)) stating treatment provided was not causally related to the compensable injury or claim has been controverted and there is no controversy (FROI/SROI 04) present in the case.
  2. Failure to continue payments consistent with the claimant's treating provider's medical reports, including reducing payments based on an IME.

Volunteer claims, Section 50 not 21-a

Benefits paid under the Volunteer Firefighter's Benefits Law (VBFL) or the Volunteer Ambulance Workers Benefits Law (VAWBL) may not be made without liability pursuant to Workers' Compensation Law (WCL) section 21-a.

When a payment is made pursuant to Section 50 of either the VBFL or VAWBL, the payer is conceding that the benefits are due. The controversy in these Section 50 cases is between potential liable parties. Payments made pursuant to VBFL or VAWBL Section 50 do not extend the payer's time to controvert the claim. The proper filing of a SROI using the Agreement to Compensate Code of "W" without liability, represents the payer is raising Section 50 on a volunteer claim.

eClaims reminders for payers

eClaims 3.1 requires payers to use an ATC (Agreement to Compensate) code on nearly all filings (that are not an 04 denial of the claim) indicating whether they are accepting the case with liability for medical and indemnity benefits (L) or without liability for medical and indemnity benefits (W). The legal significance of these filings must be interpreted within the framework of New York's Workers' Compensation Law. Two sections of the law in particular must be considered in conjunction with the payers eClaims filings: WCL 25(2)(b), which states that in the event the Board indexes a claim, the payer will waive most defenses unless it files a denial of the claim within 25 days of indexing; and NYS WCL 21-a, which states that when an insurer makes payment of medical and/or indemnity benefits without prejudice to its right to later controvert the claim, the payer must notify the claimant of this reservation of rights.


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