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 325-5.5 - General procedure for data-matching

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
Format of requests for computer
					 searches.
Health insurers participating in the match program shall
						submit requests for computer searches in a technological format prescribed by
						the chair. Such requests for computer searches shall include the claimant's
						social security number, if known, last name, initial of first name or first
						name, sex, date of birth, date of treatment, or date of accident, if known, and
						such other qualifiers permitted or required by the chair that would establish
						the identity of the claimant as the person whose payments were covered by the
						health insurer.
(b)
Time limitations.
The date of treatment or accident submitted by the health
						insurer will be matched against the date of accident contained in the board's
						file. If the date of treatment submitted by the health insurer is within 360
						days of the date of accident contained in the board file, the health insurer
						will receive a match on this time limitation criterion. A match on the time
						limitation criterion is required for all full matches.
(c)
Full matches.
The board will compare all information supplied by the
						health insurer against individually identifiable information contained in board
						case files. When there is an identity of information between the information
						supplied by the health insurer and the individually identifying information
						contained in a claimant's case file of a quality and quantity to create a
						reasonable basis for the board to determine that they are the same person,
						based on criteria set by the chair that would establish the identity of the
						claimant as the person whose payments were covered by the health insurer, the
						board shall notify the health insurer that there is a full match with respect
						to the claimant. A match on the time limitation criterion is required for all
						full matches.
(d)
Partial matches.
The board will compare all information supplied by the
						health insurer against individually identifiable information contained in board
						case files. When there is some identity of information between the information
						supplied by the health insurer and the individually identifying information
						contained in the claimant's case file, but such identity of information is not
						of a quality or quantity to create a sufficient reasonable basis for the board
						to determine that they are the same person, based upon criteria set by the
						chair that would establish the identity of the claimant as the person whose
						payments were covered by the health insurer, the board shall notify the health
						insurer that there is a partial match with respect to the claimant.
(e)
Match situations.
(1) Full match. When there is a "full
					 match,'' the board will provide the health insurer with the following
					 information:
(i) the workers' compensation
					 case number;
(ii) a description of
					 the injury or illness (if and as available in the board's computer
					 database);
(iii) the workers'
					 compensation carrier's identification number (carrier code);
(iv) the workers' compensation carrier's case
					 number (if and as available in the board's computer database);
(v) a designation as to whether the carrier
					 accepted the case by filing a C-669 (if and as available in the board's
					 computer database);
(vi) a
					 designation as to whether ANCR has been established (if and as available in the
					 board's computer database); and
(vii) a designation as to whether the case is
					 open or closed (if and as available in the board's computer database).
If there is a full match, the health insurer will be
						placed on notice for future hearings and decisions. A health insurer will only
						be placed on notice for future hearings and decisions in cases where there is a
						full match.