Current through Register Vol. 46, No. 12, March 20, 2024
(a) Notice of objection by a carrier to any
request for reimbursement by a health insurer shall be served on the health
insurer in accordance with section
325-6.15(a)
of this Subpart, within 90 days after the date the HIMP-1 form was served on
the carrier. Notwithstanding the foregoing, the parties may mutually agree in
writing to extend the period in which the carrier must serve a notice of
objection. 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.
(b) 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 acceptance of the claim or 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 and therefore the claim
is not subject to reimbursement.
(2) The request for reimbursement has not
been timely served in accordance with section
325-6.2
or section
325-6.3(b)
of this Subpart.
(3) The treatment,
services or hospitalization for which the health insurer 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.
(4) The treatment,
services or hospitalization for which the health insurer 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 or such
authorization was denied by the carrier and the claimant or health care
provider did not seek a board or Workers' Compensation Law judge determination
on the denial.
(5) 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.
(6) The bill should have been pro-rated with
another physician or health provider.
(7) The carrier cannot determine from the
documentation served whether it is responsible for payment.
(8) The carrier has previously reimbursed the
health insurer or paid the health provider with respect to the claim. Proof of
payment must be submitted.
(9) The
treatment was provided on or after the date that the board approved a waiver on
the part of the claimant to the right to medical treatment in connection with
an agreement made pursuant to Workers' Compensation Law section 32.
(10) The carrier would not be obligated to
pay for the treatment pursuant to Workers' Compensation Law section 29 because
the claimant recovered proceeds from a third party and the corresponding
carrier lien or offset has not been extinguished.
(11) The treatment provided by a board
authorized provider was not consistent with the applicable medical treatment
guidelines adopted by the board in section
324.2(a)
of this Title.
(c) 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 which demonstrates that the request for reimbursement should not
be made, unless such objection is specifically prohibited by subdivision (d) of
this section.
(d) 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 there under.
(2) The
failure of a provider to file notices and/or reports required by section
13-a(4), 13-k(3), 13-l(3) or 13-m(4) of the Workers' Compensation Law and the
rules and regulations promulgated there under.
(3) The treatment was excessive or too
frequent, except as set forth in the applicable medical treatment guidelines
adopted by the board in section
324.2(a)
of this Title.
(4) The period of
hospitalization was excessive and/or unnecessary, except as set forth in the
applicable medical treatment guidelines adopted by the board in section
324.2(a)
of this Title.
(e) Where
an objection to a request for reimbursement has been made on any of the bases
set forth in paragraphs (b)(4)-(10) and subdivision (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.
(f) 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),
325-6.7(c)
and
325-6.11(c)
of this Subpart, no objections or supporting documents will be considered
unless they have been timely served on the health insurer in accordance with
the provisions of this Subpart.
