Current through Register Vol. 46, No. 12, March 20, 2024
(a)
(1) A carrier objecting to any bill for
hospital care or for services performed by a hospital shall notify the hospital
in writing that the bill is not being paid and explain the reasons for
nonpayment within 45 days after the bill has been submitted in accordance with
section
325-1.24
or
325-1.25
of this Title. The notification shall contain the name, telephone number,
facsimile transmission number and email address, if available, of a contact
person to whom the hospital may address any inquiry regarding the carrier's
objection to the bill. The carrier shall set forth the specific basis for its
nonpayment of the bill and explain in detail the reasons supporting its
objections. Any objection which sets forth the specific basis for nonpayment
but does not explain in detail the reasons supporting the objection shall not
be considered sufficient notification in writing for purposes of this
section.
(2) Notwithstanding the
provisions of paragraph (1) of this subdivision, in any case the submission of
a notice of controversy and notice of treatment issue or bill dispute in the
format prescribed by the chair and service of the notice upon the hospital
within such 45-day period shall be deemed to be a notification in writing
explaining the reasons for nonpayment with respect to any legal objections
raised therein. In lieu of providing such notices to the hospital, the carrier
may send the hospital a sufficiently detailed written explanation raising legal
objections to the bill. If the carrier has timely submitted such notices with
the chair and served a copy of the notice upon the hospital or sent the
hospital a sufficiently detailed written explanation raising legal objections
to the bill, the carrier shall notify the hospital in writing that the bill is
not being paid and explain the reasons for nonpayment, in the same manner as
set forth in paragraph (1) of this subdivision, within 30 days after all
questions duly and timely raised with respect to the carrier's liability for
such bill have been finally determined adversely to the carrier; provided,
however, that the explanation for nonpayment shall not be on the basis of any
issues previously adjudicated by the Workers' Compensation Law judge or the
board which have been finally determined adversely to the carrier. If the
carrier files an application for review of a decision by a Workers'
Compensation Law judge, the carrier shall serve a copy of the application for
review, together with the prescribed cover sheet (form RB-89) on the hospital
simultaneously with its service on all other parties required to be served. The
carrier may notify the hospital in writing that it has filed an application for
review, in lieu of serving a copy of the application and cover sheet on the
hospital.
(3) If the carrier fails
to object to a bill in accordance with the provisions of section
325-1.24
or
325-1.25
of this Title and this subdivision, the hospital may request an administrative
award in accordance with section
325-1.24
or
325-1.25
of this Title.
(b) Upon
receipt of a timely written notification of the carrier's explanation for
nonpayment in accordance with subdivision (a) of this section, the hospital may
request arbitration by notifying the chair in accordance with the following:
(1) if the carrier has not raised legal
objections to the bill, the request for arbitration shall be submitted a
minimum of 45 days after the date of the hospital's submission of the bill to
the carrier, but no later than 120 days after receipt of notification of
nonpayment, or
(2) if the carrier
has raised legal issues, the request for arbitration shall be submitted
subsequent to the hospital's receipt of the carrier's written explanation for
nonpayment but in any event no earlier than 30 days after the date of notice of
a final decision by the Workers' Compensation Law judge or the board in favor
of the hospital with respect to issues requiring adjudication, and no later
than the later of 120 days after either the date of filing of such decision or
the date of receipt of the carrier's explanation for nonpayment.
(b) If the hospital wishes to
arbitrate, it shall complete and sign the request form for arbitration and
forward it to the address specified on such form. The hospital's failure to
make a timely request for arbitration shall be deemed a waiver of the right to
arbitration; provided, however, that upon application of the hospital, the
chair may for good cause excuse the hospital for the delay in filing the
request for arbitration and schedule the disputed bill for
arbitration.
(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.