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 325-6.4 - Objections to requests for reimbursement

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Notice of objection by a carrier to any
					 request for reimbursement by a health insurer shall be served on the health
					 insurer in accordance with section
					 325-6.15(a) 
					 of this Subpart, within 90 days after the date the HIMP-1 form was served on
					 the carrier. Notwithstanding the foregoing, the parties may mutually agree in
					 writing to extend the period in which the carrier must serve a notice of
					 objection. The basis for objection shall be specified on the HIMP-1 form or
					 copy thereof which was sent by the health insurer to the carrier.
(b) The following issues may be interposed by
					 a carrier as objections to requests for reimbursement, in whole or in part, by
					 a health insurer:
(1) The compensability of
					 the claim has not been established or the workers' compensation case has been
					 closed without acceptance of the claim or findings of accident or occupational
					 disease, notice and causal relationship, or the compensability of the claim is
					 the subject of a pending application for review to the board or a pending
					 appeal to the courts, and is not subject to arbitration and therefore the claim
					 is not subject to reimbursement.
(2) The request for reimbursement has not
					 been timely served in accordance with section
					 325-6.2 
					 or section
					 325-6.3(b) 
					 of this Subpart.
(3) The treatment,
					 services or hospitalization for which the health insurer made payments was on
					 behalf of a person other than the workers' compensation claimant, or was for a
					 condition or injury unrelated to the workers' compensation claim, or for
					 treatment of a part of the body for which causal relationship has not been
					 established.
(4) The treatment,
					 services or hospitalization for which the health insurer made payments were not
					 furnished on an emergency basis, and were obtained by the injured employee
					 after authorization for such treatment, services or hospitalization was
					 requested by the injured employee and such authorization was denied by a
					 Workers' Compensation Law judge or other duly designated board employee or such
					 authorization was denied by the carrier and the claimant or health care
					 provider did not seek a board or Workers' Compensation Law judge determination
					 on the denial.
(5) The fee was in
					 excess of the workers' compensation fee schedule or, in the case of inpatient
					 hospital bills, in excess of the rate of payment for inpatient hospital
					 services established pursuant to the provisions of the Public Health Law, or
					 the proper fee schedule amount or rate of payment for inpatient hospital
					 services cannot be determined. In any case in which this objection is
					 interposed, the carrier must explain why the fee was in excess of the fee
					 schedule or rate of payment or why the proper amount cannot be determined. If
					 this is the sole objection to the request for reimbursement, the carrier must
					 state the amount which it believes to be the proper amount and must pay the
					 undisputed amount to the health insurer.
(6) The bill should have been pro-rated with
					 another physician or health provider.
(7) The carrier cannot determine from the
					 documentation served whether it is responsible for payment.
(8) The carrier has previously reimbursed the
					 health insurer or paid the health provider with respect to the claim. Proof of
					 payment must be submitted.
(9) The
					 treatment was provided on or after the date that the board approved a waiver on
					 the part of the claimant to the right to medical treatment in connection with
					 an agreement made pursuant to Workers' Compensation Law section 32.
(10) The carrier would not be obligated to
					 pay for the treatment pursuant to Workers' Compensation Law section 29 because
					 the claimant recovered proceeds from a third party and the corresponding
					 carrier lien or offset has not been extinguished.
(11) The treatment provided by a board
					 authorized provider was not consistent with the applicable medical treatment
					 guidelines adopted by the board in section
					 324.2(a) 
					 of this Title.