New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter C - Medical Treatment and Care › Part 325 - Medical And Surgical Care And Treatment › Subpart 325-6 - Reimbursement for workers' compensation claims paid by health insurers; arbitration of disputed requests for reimbursement › Section 325-6.1 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
As used in this Subpart:
(a)
Acceptance of claim
shall mean the filing of notice in the format prescribed by the chair of the
					 carrier's acceptance of a claim of benefits.
(b)
Accident
shall include
					 both an accident arising out of and in the course of employment and an
					 occupational disease. In the case of occupational disease, date of accident,
					 where used in this Subpart, shall mean date of disablement.
(c)
ANCR
shall mean
					 accidental injury or occupational disease, notice and causal
					 relationship.
(d)
Board
shall mean the Workers' Compensation Board, and in the
					 case of board determinations shall include those made by a member or panel of
					 the board, by a Workers' Compensation Law judge, conciliator or by the full
					 board.
(e)
Carrier
shall mean a self-insured or uninsured employer, or workers' compensation
					 insurance carrier as defined in section
					 300.1(a)(7) 
					 of this Title, or special fund created by the Workers' Compensation Law for
					 payment of workers' compensation claims, but shall not include the uninsured
					 employers' fund.
(f)
Chair
shall mean the chairperson of the Workers' Compensation
					 Board of the State of New York.
(g)
Dispute forum
shall mean the American Arbitration Association
					 or such other private arbitration association or forum for alternative dispute
					 resolution designated by the chair and posted on the board's website to
					 arbitrate disputed requests for reimbursement.
(h)
Health insurer
shall
					 mean a health insurer, health benefits plan or other payor of health benefits
					 as defined in section 13 (d)  of the Workers' Compensation Law, when acting
					 directly or through a HIMP agent.
(i)
HIMP
means the Health
					 Insurance Matching Program authorized by section 13 (d) and (h)  of the Workers'
					 Compensation Law and refers to processes established by the board to assist a
					 health insurer in reimbursement from a carrier for payments made for medical
					 and/or hospital services for or on behalf of an injured employee, and for
					 arbitration of disputed claims for reimbursement.
(j)
HIMP agent
shall mean a
					 person or entity that is designated and authorized by a health insurer to
					 submit information for matching under this Subpart and to seek reimbursement
					 from a carrier under this Subpart on behalf of the health insurer. A HIMP agent
					 must execute a written agreement, prescribed by the chair, between the HIMP
					 agent, the health insurer and the board and file such agreement with the board.
					 In addition a HIMP agent must comply with all laws, regulations and policies
					 applicable to health insurers as set forth in Workers' Compensation Law section
					 13(d) and (h), and this Part. Failure to comply with all terms of such written
					 agreement or such other agreements with the board or with all applicable laws,
					 regulations, and policies is grounds for termination of an individual or
					 entity's status as HIMP agent and to preclude its participation in and rights
					 under Workers' Compensation Law section 13(d) and (h), and this Part.
(k)
Provider
shall mean a
					 physician, hospital, physical or occupational therapist, podiatrist,
					 chiropractor, psychologist or other health provider to whom payment has been
					 made by the health insurer.