reglab/statecodes huggingface dataset:
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 325-4 - Authorization Of Hospitals And Health Maintenance Organizations › Section 325-4.4 - Inspections and investigations by the department of health

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The Department
					 of Health shall have 180 days from the chairman's request for an inspection and
					 investigation pursuant to subdivision 4(g)(i) of section 13-c  of the Workers'
					 Compensation Law, in which to refer its report and recommendations to the
					 chairman.
(b) The Department of
					 Health shall send notice to the chairman of all decisions rendered in any
					 enforcement action commenced by the Department of Health against an authorized
					 hospital or health maintenance organization with respect to its out-patient
					 medical care and facilities.
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 325-4 - Authorization Of Hospitals And Health Maintenance Organizations › Section 325-4.5 - Suspension or revocation of authorization

Current through Register Vol. 46, No. 28, July 10, 2024
The chair may suspend or revoke the authorization of a
						hospital or health maintenance organization after a hearing, upon a finding
						that:
(a) the hospital or health
					 maintenance organization has been guilty of professional or other
					 misconduct;
(b) the hospital or
					 health maintenance organization has violated any of the provisions of the
					 Workers' Compensation Law, or the rules promulgated thereunder;
(c) the personnel of the hospital or health
					 maintenance organization rendering medical care to workers' compensation
					 claimants is not properly qualified under the Workers' Compensation Law;
					 or
(d) the equipment of the
					 hospital or health maintenance organization is inadequate for the proper
					 rendering of medical care.
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 325-4 - Authorization Of Hospitals And Health Maintenance Organizations › Section 325-4.6 - Procedure for hearing

Current through Register Vol. 46, No. 28, July 10, 2024
In any hearing pertaining to the suspension or revocation
						of the authorization of a hospital or health maintenance organization, the
						following procedure shall apply:
(a)
					 The hearing shall be conducted by the Medical Appeals Unit.
(b) The accused hospital or health
					 maintenance organization shall be given 30 days' notice in writing, containing
					 a brief statement of the charge or charges against such hospital or hospitals
					 and health maintenance organizations and the time when and the place where such
					 charge or charges will be heard. Such notice shall be served either personally
					 or by mail. At least 10 days prior to the hearing date fixed in said notice,
					 the accused hospital or health maintenance organization shall file an answer to
					 such charges with the Medical Appeals Unit.
(c) At the hearing on such charge or charges,
					 the accused hospital or health maintenance organization shall be entitled to
					 have counsel present and to cross-examine witnesses. A verbatim record of the
					 proceedings shall be made, and witnesses shall testify under oath.
(d) The Medical Appeals Unit in the conduct
					 of a hearing shall not be bound by common law or statutory rules of evidence,
					 or by technical or formal rules or procedure, except as provided herein; and
					 may make such investigation or inquiry and conduct such hearing in the manner
					 it deems advisable and necessary.
(e) A decision concurred in by two of the
					 three members of the Medical Appeals Unit shall constitute the decision of the
					 Medical Appeals Unit. The decision of the Medical Appeals Unit shall be
					 advisory to the chairman and shall not be binding or conclusive.
(f) A copy of the record of the proceeding
					 shall be submitted to the chair together with the report, findings and
					 recommendation of the Medical Appeals Unit.
(g) Until final action is taken by the chair
					 on the findings and recommendation of the Medical Appeals Unit, the accused
					 hospital or health maintenance organization may continue to provide out-patient
					 medical treatment and care under the Workers' Compensation Law, unless
					 otherwise specifically ordered by the chair.
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 325-5 - Computer match between health insurers and workers' compensation carriers › Section 325-5.1 - Statement of purpose

Current through Register Vol. 46, No. 28, July 10, 2024
The purpose of subdivisions (d) and (h) of section 13  of
						the Workers' Compensation Law and this Subpart is to assist health insurers in
						the identification of claims that they have paid which may be the
						responsibility of the employer, workers' compensation insurance carrier, or
						special fund, and to obtain reimbursement thereof. This Subpart also intends to
						regulate the behavior of HIMP agents as defined in section
						325-5.2(h) 
						of this Subpart.
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 325-5 - Computer match between health insurers and workers' compensation carriers › Section 325-5.3 - Overview of the HIMP process

Current through Register Vol. 46, No. 28, July 10, 2024
The Workers' Compensation Board shall conduct computer
						searches at least quarterly upon the request of health insurers upon their full
						compliance with these regulations. Health insurers desiring such searches shall
						submit to the Board the required information including all data elements in a
						technological format prescribed by the Chair. Such information shall be
						compared with the computer records of the Board, in order to identify claimants
						whose social security number, name, date of accident, date of birth, or other
						qualifiers match dates of treatment submitted by the health
						insurer.
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 325-5 - Computer match between health insurers and workers' compensation carriers › Section 325-5.4 - Eligibility to participate in the HIMP process

Current through Register Vol. 46, No. 28, July 10, 2024
Only a health insurer shall be eligible to participate in
						this program. A health insurer may contract with a HIMP agent, as defined in
						sections
						325-5.2(h)
						 and
						325-6.1(i) 
						of this Part, to act on its behalf. The HIMP agent must satisfy all
						requirements set forth in section
						325-5.2(h)
						 and
						325-6.1(i) 
						of this Part to maintain its eligibility to participate in this
						program.
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 325-5 - Computer match between health insurers and workers' compensation carriers › Section 325-5.6 - Payment for searches; process for submission of search requests

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
Fees for
					 computer match process.
(1) The board
					 will charge a health insurer $0.045 for each search request submitted through
					 the computer match process. Where multiple searches of the same record are
					 required, there shall be a charge for each search. Payment shall be made in a
					 form acceptable to the chair and must be received prior to the board performing
					 the computer search.
(2) Submission
					 of data; payment. A health insurer shall identify the number of claims
					 submitted and the total cost as per the rates cited in paragraph (a)(1) of this
					 section in a manner and at a time prescribed by the chair as periodically
					 provided to the health insurer by written or electronic notice or such method
					 as shall be provided in such notice.
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 325-5 - Computer match between health insurers and workers' compensation carriers › Section 325-5.7 - Annual reporting

Current through Register Vol. 46, No. 28, July 10, 2024
No later than March 31st of each year, each health
						insurer and HIMP agent participating in this program shall send a report to the
						Chair indicating the total amount of reimbursement requested and recovered, the
						total number of HIMP-1 forms submitted for reimbursement, the total number of
						requests for arbitration submitted in the prior calendar year as a result of
						this program, identifying the number of requests for a desk arbitration and the
						number of requests for an oral hearing, and including the number of
						arbitrations resolved in favor of the health insurer. Each health insurer and
						HIMP agent shall report the name of each medical provider for which it has
						discovered duplicate payment made by the health insurer and the carrier and the
						number of such duplicate payments made in the prior calendar
						year.
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 325-5 - Computer match between health insurers and workers' compensation carriers › Section 325-5.8 - Confidentiality of information

Current through Register Vol. 46, No. 28, July 10, 2024
Misuse of confidential information; penalties. A health
						insurer and HIMP agent receiving information pursuant to subdivisions (d) and
						(h) of section 13  of the Workers' Compensation Law and this Subpart shall use
						such information solely for the purpose of seeking reimbursement from the
						employer, workers' compensation insurance carrier or special fund. Every
						agreement between a health insurer and a HIMP agent shall specify that the HIMP
						agent may be terminated by the Board for misuse of confidential information.
						Upon notification to the Chair that either a health insurer or a HIMP agent has
						used such information for purposes other than those stated above, an
						administrative hearing shall be held before an employee of the Board,
						designated by the Chair to conduct such hearings. The Chair, upon a finding
						that such information has been used by a health insurer or a HIMP agent for
						purposes other than that stated above, may, after such hearing, impose a
						penalty of not more than $10,000, and may prohibit such health insurer and HIMP
						agent from receiving information under subdivisions (d) and (h) of section 13 
						of the Workers' Compensation Law and this Subpart, for a period of up to three
						years. Additionally, a health insurer and HIMP agent receiving information
						pursuant to subdivision (h) of section 13  of the Workers' Compensation Law and
						this Subpart, shall comply with all applicable federal and state laws and
						regulations regarding the confidentiality of such information, including but
						not limited to section 110-a  of the Workers' Compensation Law. In addition to
						any other available penalty or remedy at law, the Chair, upon a finding that
						such information has been used by a HIMP agent for purposes other than as
						stated above, may immediately terminate such individual or entity's status as a
						HIMP agent.
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 325-5 - Computer match between health insurers and workers' compensation carriers › Section 325-5.9 - Waiver of timely submission of bills

Current through Register Vol. 46, No. 28, July 10, 2024
Sections
						325-1.25(b),
						327.3(c),
						328.3(c),
						342.2(c),
						347.3(b)
						 and
						349-2.3(b) 
						of this Title shall not apply where there is a "full match'' under section
						325-5.5 
						of this Subpart.
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 325-5 - Computer match between health insurers and workers' compensation carriers › Section 325-5.10

Current through Register Vol. 46, No. 28, July 10, 2024
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 325-5 - Computer match between health insurers and workers' compensation carriers › Section 325-5.11

Current through Register Vol. 46, No. 28, July 10, 2024
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 325-6.2 - Filing requests for reimbursement

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The health insurer shall be responsible
					 for initiating claims for reimbursement of amounts paid by them which may be
					 the responsibility of the carrier, as provided in Workers' Compensation Law
					 section 13(d). The health insurer shall develop with the carrier its own
					 mechanisms and standard operating procedures for payment of undisputed claims
					 for reimbursement.
(b) Claims for
					 reimbursement must be filed within three years of the date of payment by the
					 health insurer for services rendered by a provider as provided in Workers'
					 Compensation Law section 13(d). Claims for reimbursement are deemed filed with
					 the board by submission of a request for a record search to the board in the
					 format prescribed by the chair, pursuant to Subpart 325-5 of this Part, to
					 identify claims which may be the responsibility of the carrier. If a health
					 insurer receives a full match to a workers' compensation claim, the health
					 insurer shall not be required to submit further records of treatments that are
					 causally related to the same accident. The date of submission of the treatment
					 that resulted in a full match shall be applicable to all subsequent treatments
					 causally related to the same accident for purposes of the three year service
					 requirement. HIMP-1 forms shall neither be served on nor accepted by the board.
					 No request for reimbursement may become eligible for arbitration unless it has
					 been timely filed and served in accordance with the provisions of this
					 section.
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 325-6.3 - HIMP-1 filing procedures and documentation

Current through Register Vol. 46, No. 28, July 10, 2024
(a) A health insurer requesting reimbursement
					 must serve the HIMP-1 form, or other form or format for request prescribed by
					 the chair, on the carrier before such request may become eligible for
					 arbitration. The HIMP-1 form may only be served on the carrier after the health
					 insurer is notified of a "full match'' pursuant to Subpart 325-5 of this
					 Part.
(b) The following time
					 limitations shall govern requests for reimbursement by a health insurer:
(1) The health insurer must submit the data
					 concerning medical treatment to the board for a match or have received a full
					 match in connection with the same workers' compensation claim within three
					 years of the date of payment for services rendered by the health care provider
					 to be eligible for arbitration.
(2)
					 A health insurer must serve a HIMP-1 form on the carrier, in accordance with
					 section
					 325-6.15(a) 
					 of this Subpart, within one year of the latest date of the following:
(i) the acceptance of the claim or the
					 establishment of ANCR to the particular body part or disease in
					 question;
(ii) the date the board
					 notifies the health insurer of the full match pursuant to Subpart 325-5 of this
					 Part;
(iii) the date of payment for
					 services; or
(iv) the effective
					 date of this Part.
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 325-6.5 - Eligibility for arbitration

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Except
					 as provided in subdivision (b) of this section, all claims for reimbursement by
					 a health insurer which have been timely served in accordance with the
					 provisions of section
					 325-6.2 
					 of this Subpart are eligible for and subject to mandatory arbitration to be
					 conducted under this Subpart provided the carrier:
(1) fails to make full payment or serve an
					 objection within 90 days after the date of service of the HIMP-1 form by the
					 health insurer on the carrier; or
(2) serves an objection to reimbursement to
					 the health insurer within 90 days after the date of service of the HIMP-1 form
					 by the health insurer.
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 325-6.6 - Time to request arbitration

Current through Register Vol. 46, No. 28, July 10, 2024
(a) A
					 health insurer requesting arbitration must send such request for arbitration to
					 the dispute forum on the HIMP-1 form, in accordance with sections
					 325-6.7
					 and
					 325-6.15  of this
					 Subpart:
(1) within 90 days after the date on
					 which the carrier served its notice of objection on the HIMP-1 form to the
					 health insurer; or
(2) if the
					 carrier has not made payment or served an objection to the health insurer:
(i) within 90 days from the expiration of the
					 period within which an objection or payment was required to be made;
					 and
(ii) in no event earlier than
					 95 days from the date on which the HIMP-1 form requesting reimbursement was
					 initially sent by the health insurer to the carrier.
Notwithstanding the foregoing, the parties may mutually
						agree in writing to extend the period in which the carrier must reply to a
						request for reimbursement.
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 325-6.7 - Initiation of arbitration

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
(1) The health insurer shall initiate the
					 request for arbitration by serving the completed HIMP-1 form requesting
					 arbitration and supporting documents on the carrier.
(2) The health insurer shall serve two copies
					 of the completed HIMP-1 form requesting arbitration and supporting documents,
					 proof of service of the request for arbitration upon the carrier, and the
					 prescribed filing fee on the dispute forum.
(3) In the event that the carrier has failed
					 to serve a notice of objection to the request for reimbursement within 90 days
					 in accordance with section
					 325-6.4 
					 of this Subpart, the health insurer shall state in the request for arbitration
					 that no objections have been received and shall provide proof of service of the
					 initial HIMP-1 form upon the carrier.
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 325-6.8 - Withdrawal of arbitration requests

Current through Register Vol. 46, No. 28, July 10, 2024
The parties may, by mutual agreement, withdraw the
						request for arbitration on a form prescribed by the dispute forum for that
						purpose. Such form must be signed by the parties and served on the dispute
						forum. If requested by the parties, their agreement to withdraw may be
						incorporated in an arbitration award. Additionally, the health insurer may
						unilaterally withdraw a request for arbitration by serving such request for
						withdrawal on the dispute forum and serving a copy to the other party. Where
						the request for arbitration has been withdrawn, fees paid to the dispute forum
						shall not be refundable, except as provided in section
						325-6.10(b) 
						of this Subpart. No request for arbitration may be unilaterally withdrawn
						unless the withdrawing party has reimbursed the other party for any
						non-refundable fee which such other party has paid to the dispute
						forum.
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 325-6.9 - Time and place of arbitration; notification

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Unless either party requests an oral
					 hearing, all hearings shall be desk arbitrations based on documents
					 alone.
(b) A health insurer
					 requesting an oral hearing must make such request together with the service of
					 its request for arbitration. A carrier may make a request for an oral hearing
					 within 14 days after receipt of its copy of the request for arbitration. Such
					 request must be made in writing to the dispute forum, and a copy of such
					 request must be simultaneously served on the health insurer.
(c) The dispute forum shall set the location,
					 date and time of oral hearing and shall notify the parties no less than 14 days
					 in advance of such oral hearing. The dispute resolution may utilize video
					 conferencing or such other technology to enable the parties to participate in
					 the oral hearing from disparate locations.
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 325-6.10 - Fee structure

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The
					 health insurer shall, together with its request for arbitration, submit a
					 nonrefundable filing fee in the amount of $175 per request to the dispute
					 forum. For desk arbitrations, the arbitrator shall receive a fee of $60 per
					 arbitration, payable by the dispute forum from the filing fees received by
					 it.
(b) In the event either party
					 shall demand an oral hearing, a fee in the amount of $475, of which $250 shall
					 be paid to the arbitrator, shall be paid to the dispute forum together with
					 such demand. The party requesting the oral hearing shall pay an additional sum
					 of $250 as the arbitrator's fee for any additional day of oral hearing. In the
					 event the request for oral hearing is withdrawn prior to the commencement of
					 the oral hearing, the sum of $250 representing the arbitrator's fee shall be
					 refunded by the dispute forum to the party requesting such hearing.
(c) In the event of a request for
					 reconsideration, pursuant to section
					 325-6.12(d) 
					 of this Subpart, the dispute forum shall pay the arbitrator $75 of the
					 additional filing fee.
(d) The fees
					 payable pursuant to the provisions of this section shall apply to all requests
					 for arbitration properly served on the dispute forum 90 days after the
					 effective date of this Subpart as a final rule.
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 325-6.13 - Enforcement and appeals of decisions

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Any decisions of an arbitrator made
					 pursuant to the provisions of this Subpart may be enforced, vacated or modified
					 in accordance with the applicable provisions of sections 7509, 7510, 7511 and
					 7514  of the Civil Practice Law and Rules. No other provisions of article 75 of
					 the Civil Practice Law and Rules, except as may be otherwise provided in this
					 Subpart, shall be applicable to arbitration pursuant to this Subpart. The
					 arbitrator, dispute forum and the board shall not be made parties to a court
					 proceeding relating to an arbitration award. The participation of a party in
					 such an arbitration proceeding shall be a waiver of any claim against an
					 arbitrator or the dispute forum for any act or omission in connection with any
					 arbitration conducted under these rules.
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 325-6.14 - Dispute forum rules

Current through Register Vol. 46, No. 28, July 10, 2024
All parties subject to the provisions of this Subpart
						shall be subject to any rules promulgated by the dispute forum with respect to
						its own internal procedures regarding the administration of disputed requests
						for reimbursement, to the extent that such rules are not inconsistent with this
						Subpart.
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 325-6.15 - Means of service

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
Pre-arbitration.
The health insurer and carrier shall serve the request
						for reimbursement and any payments or objections thereto using the HIMP-1 form.
						Service shall be effective if performed by:
(1) personal delivery;
(2) first class mail;
(3) certified mail return receipt
					 requested;
(4) overnight delivery
					 service;
(5) facsimile
					 transmission, provided that the receiving party has designated a facsimile
					 number for this purpose to the other party or the board;
(6) electronic mail with confirmation of
					 delivery, provided that the receiving party has designated an electronic mail
					 address for this purpose to the other party or the board; or
(7) such other means of delivery (electronic
					 or otherwise) as is agreed upon between the carrier and the insurer in a
					 written agreement.
Service by facsimile transmission shall be complete upon
						the receipt by the sender of a signal from the equipment of the carrier served
						indicating that the transmission was received. Service by electronic mail shall
						be complete upon the receipt of confirmation of electronic delivery.
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 325-6.16 - Party modification of HIMP

Current through Register Vol. 46, No. 28, July 10, 2024
A health insurer and a carrier may agree to modify
						certain aspects of the HIMP reimbursement process, including the deadlines for
						service, the means of service between the parties, the conditions required for
						reimbursement, or other aspects of HIMP reimbursements, by executing a written
						agreement setting forth any such modified conditions and specifying whether the
						modifications shall be enforceable through arbitration.
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 325-6.17 - Qualifications of arbitrators

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
					 The chair shall appoint an advisory committee composed of four members who will
					 review the qualifications of applicants for the position of arbitrator of
					 disputed requests for reimbursement and review their performance. The advisory
					 committee shall make recommendations in a timely manner to the chair pertaining
					 to the appointment and dismissal of arbitrators. The committee shall consist of
					 one representative each of the AFL-CIO, the Business Council of New York, the
					 State Insurance Fund, and the board.
(b) An arbitrator shall have a basic
					 knowledge of the Workers' Compensation Law which will qualify such arbitrator
					 to resolve issues involved in reimbursement disputes. Documentation of such
					 knowledge and related experience shall be submitted to the advisory
					 committee.
(c) All arbitrators
					 shall be appointed by, and serve at the pleasure of, the chair and subject to
					 the following:
(1) The arbitrator shall serve
					 a term of three years. Such term shall run from the date of appointment by the
					 chair or the effective date of this regulation whichever date is later. The
					 three year term shall expire on March 31st of the third year following the year
					 of appointment. Renewal shall be at the discretion of the chair. An arbitrator
					 shall continue to serve, following March 31st of the third year, pending
					 renewal by the chair.
(2) An
					 arbitrator candidate shall disclose to the chair any circumstance which is
					 likely to create an appearance of bias or which might disqualify such a person
					 as an arbitrator, and the chair shall determine whether the candidate should be
					 disqualified. The chair shall forward the names of all arbitrators to the
					 dispute forum, and promptly inform the dispute forum of all additions to, and
					 deletions from, the panel of arbitrators.
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 325-6.18 - Appointment of arbitrators

Current through Register Vol. 46, No. 28, July 10, 2024
The dispute forum shall select from the panel of
						arbitrators, on a rotational basis, an arbitrator who will hear the case and
						shall submit the name of the arbitrator to each party to the arbitration. Any
						person appointed as an arbitrator shall disclose to the dispute forum any
						circumstance likely to affect impartiality, including any bias, financial
						and/or personal interest in arbitration. Upon receipt of such information from
						the arbitrator or another source, the dispute forum shall communicate the
						information to the parties, and if it deems appropriate to do so, to the
						arbitrator and other interested parties. If a party objects to the appointment
						of an arbitrator, the specific grounds for such objection shall be submitted in
						writing to the dispute forum, which shall determine within 15 days after
						receipt of the challenge whether the arbitrator shall be disqualified. The
						dispute forum shall determine whether the arbitrator shall be disqualified and
						shall notify the parties of its decision, which shall be final and binding. In
						the event an arbitrator shall resign, be disqualified or be otherwise unable to
						perform his or her duties, the dispute forum shall appoint another
						arbitrator.
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 325-6.19 - Oaths

Current through Register Vol. 46, No. 28, July 10, 2024
All arbitrators shall be required to take an annual oath
						of office. Arbitrators shall require all witnesses to testify under oath or
						affirm that their statements are true under penalty of
						perjury.
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 325-7 - Diagnostic Testing Networks › Section 325-7.2 - Insurance carrier requirements to contract with diagnostic testing networks

Current through Register Vol. 46, No. 28, July 10, 2024
(a) An
					 insurance carrier may contract with a legally and properly organized diagnostic
					 testing network or networks as permitted by this Subpart and Workers'
					 Compensation Law section 13-a(7) and in accordance with all applicable
					 law.
(b) An insurance carrier that
					 contracts with a diagnostic testing network or networks pursuant to this
					 Subpart may require claimants to obtain or undergo diagnostic examinations and
					 tests with an affiliated network provider.
(c) In order for an insurance carrier to
					 require claimants to obtain or undergo diagnostic examinations and tests with
					 an affiliated network provider, the insurance carrier, or through a designated
					 diagnostic testing network or networks if permitted by law, must:
(1) file with the chair, or his or her
					 designee:
(i) a list of all diagnostic
					 testing networks it has contracted with under this section, which list shall
					 include the name, mailing address, toll-free telephone number, email address
					 and website address for the diagnostic testing network and the name and contact
					 information for the manager of the diagnostic testing network or other party
					 listed as the contact;
(ii)
					 certification from the diagnostic testing network(s) it has contracted with
					 that such diagnostic network has filed with the chair a list of the names and
					 physical addresses of the medical facility or professional office location(s)
					 where diagnostic examinations and tests will be performed and will file any
					 changes to such list with the chair within 20 business days;
(iii) certification from the diagnostic
					 testing network(s) it has contracted with that such diagnostic network has
					 filed with the chair a list of the diagnostic examinations and tests offered at
					 each medical facility or professional office location listed in subparagraph
					 (ii) of this paragraph and will file any changes to such list with the chair
					 within 20 business days; and
(iv)
					 certification from the diagnostic testing network(s) it has contracted with
					 that such diagnostic network has filed with the chair a list of the names and
					 addresses of the licensed medical providers who may perform and/or interpret
					 the diagnostic examinations and tests at each listed location and will file any
					 changes to such list with the chair within 20 business days;
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 325-7 - Diagnostic Testing Networks › Section 325-7.4 - Services provided by diagnostic testing networks and affiliated network providers

Current through Register Vol. 46, No. 28, July 10, 2024
(a) To the
					 extent permitted by law, diagnostic testing networks and affiliated network
					 providers shall be authorized to:
(1) schedule
					 diagnostic examinations and tests of claimants with affiliated network
					 providers;
(2) provide the notice
					 required by section
					 325-7.5(d) 
					 of this Subpart; and
(3) process,
					 pay, and raise any objections to bills for diagnostic examinations and
					 tests.
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 325-7 - Diagnostic Testing Networks › Section 325-7.5 - Procedures for use of diagnostic testing network

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Required use of diagnostic testing
					 network.
(1) A claimant must obtain
					 diagnostic examinations and tests through a diagnostic testing network when:
(i) the insurance carrier responsible for
					 claimant's claim has contracted with a diagnostic testing network that is in
					 compliance with Workers' Compensation Law section 13-a(7) and this Subpart and
					 requires claimant to obtain or undergo diagnostic examinations and tests with
					 an affiliated network provider; and
(ii) the insurance carrier responsible for
					 the claimant's claim has provided the notification required in paragraph (d)(1)
					 of this section.
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 325-7 - Diagnostic Testing Networks › Section 325-7.6 - Alterations

Current through Register Vol. 46, No. 28, July 10, 2024
Any diagnostic testing network, affiliated network
						provider, person employed by a diagnostic testing network or affiliated network
						provider, or insurance carrier that alters or edits, or causes the alterations
						or edits of any diagnostic examinations and tests so as to render them
						inaccurate or a misrepresentation of the results, the results or reports of
						such examinations and tests, or otherwise misrepresents the findings to the
						claimant's treating medical provider who requested such diagnostic examinations
						and tests, the board, or any party of interest, shall be ineligible to contract
						with insurance carriers as a diagnostic testing network or be an affiliated
						network provider pursuant to Workers' Compensation Law section 13-a(7) and this
						Subpart. The actions of an employee or a contractor may be imputed to the
						affiliated network provider and the diagnostic testing network. In addition,
						the chair or his or her designee may make a referral to the Workers'
						Compensation Fraud Inspector General for investigation.
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 325-7 - Diagnostic Testing Networks › Section 325-7.7 - Improper influence in diagnostic testing

Current through Register Vol. 46, No. 28, July 10, 2024
(a) No person, including but not limited to
					 the employer, insurance carrier, or any of their agents, contractors, servants
					 or employees shall interfere with the selection by a claimant of an affiliated
					 network provider except to the extent that the insurance carrier provides a
					 list of affiliated network providers in accordance with section
					 325-7.5(d)(1)(i)(c)
					 and (h)  of this Subpart; nor shall any
					 insurance carrier influence or attempt to influence the medical opinion or
					 diagnostic test results of any affiliated network provider, by whom or through
					 which diagnostic examinations and tests were performed and which examinations
					 or tests are interpreted within the meaning of Workers' Compensation Law
					 section 13-a(7) and this Subpart. Nothing in this section shall prevent a
					 carrier from recommending the use of a particular affiliated network
					 provider.
(b) Insurance carriers
					 shall not participate in the performance of diagnostic examinations and tests,
					 or any reports resulting from such diagnostic examinations and tests of a
					 claimant.
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 325-8 - Preferred Provider Organization Arrangements › Section 325-8.1 - Preferred provider organization treatment; alternative care

Current through Register Vol. 46, No. 28, July 10, 2024
Subject to the duty to collectively bargain, all
						employees of an employer who has elected to utilize its workers' compensation
						insurance carrier's selected preferred provider organization shall obtain
						initial treatment from such preferred provider organization. Any employee may
						seek treatment from outside of the preferred provider organization 30 days
						after his or her initial treatment from a preferred provider organization
						provider.
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 325-8 - Preferred Provider Organization Arrangements › Section 325-8.2 - Employers' responsibilities

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
					 Any employer utilizing the services of a certified preferred provider
					 organization shall distribute to all of its employees a written notice of the
					 preferred provider organization arrangement for the treatment of all workers'
					 compensation injuries and illnesses. Such written notice shall also advise
					 potential claimants that they may obtain more detailed informational materials
					 regarding the preferred provider organization from the employer.
(b) Where there is a duty to collectively
					 bargain for the utilization and implementation of a preferred provider
					 organization, an employer must engage in such bargaining and must file with the
					 board a notarized affirmation signed by the collective bargaining agent(s)
					 confirming that the requisite negotiation of the selection of a preferred
					 provider organization has taken place and that the particular union and
					 individual agent(s) which have agreed to such preferred provider organization
					 are the recognized or certified exclusive bargaining representatives of the
					 covered employees. All agreements shall clearly state the duration of such
					 agreement and all subsequent agreements shall be subject to the same prior
					 review and approval by the collective bargaining agent(s).
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 325-8 - Preferred Provider Organization Arrangements › Section 325-8.3 - Preferred provider organization providers' responsibilities

Current through Register Vol. 46, No. 28, July 10, 2024
Preferred provider organization providers must submit
						full and truthful reports of their findings to the employer and the board.
						Providers who improperly alter or edit their reports or otherwise misrepresent
						their findings to the employer or the board will have their authorization
						revoked by the chair in accordance with sections 13-d, 13-k, 13-l and 13-m  of
						the Workers' Compensation Law.
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 325-8 - Preferred Provider Organization Arrangements › Section 325-8.4 - Reporting requirements

Current through Register Vol. 46, No. 28, July 10, 2024
All insurance carriers and self-insured employers who
						have contracted with a preferred provider organization for the treatment of
						workers' compensation injuries and illnesses shall report to the chair the
						names and addresses of insured employers who have elected to utilize the
						preferred provider organization. As required by the chair, such carriers and
						self-insured employers shall also report to the chair, in a prescribed format,
						specified data pertaining to utilization, quality of care, costs and
						outcomes.