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 325-5.2 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
As used in this Subpart:
(a)
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.
(b)
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.
(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)
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.
(h)
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.
(i)
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 Subpart 325-6 of this Part 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.