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 325-6.11 - Hearing of cases

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The
					 arbitrator shall determine initially whether the claim is eligible for or
					 subject to mandatory arbitration. If the arbitrator determines that the claim
					 is not eligible pursuant to section
					 325-6.5(b) 
					 of this Subpart, the claim shall not be arbitrated and the arbitrator shall
					 notify the parties in writing. Any party aggrieved by the arbitrator's
					 determination may, within 30 days after notification by the arbitrator, serve
					 on the dispute forum, upon notice to the other party, a request that the
					 arbitrator issue a decision pursuant to section
					 325-6.12 
					 of this Subpart denying the claim on the basis that the claim is not eligible
					 for or subject to mandatory arbitration. Such decision may be appealed pursuant
					 to section
					 325-6.13 
					 of this Subpart.
(b) The arbitrator
					 shall not be bound by common law or statutory rules of evidence or by technical
					 or formal rules of procedure but may make such investigation or inquiry and
					 conduct the hearing in such manner as he or she deems proper and necessary, and
					 shall have the power to issue subpoenas, in accordance with section 7505  of the
					 Civil Practice Law and Rules. In any oral hearing, the health insurer may
					 present its case, call witnesses and present proofs, and submit to questions
					 thereon. The defending carrier may present its defense, call its witnesses,
					 present its proofs and submit to questions thereon. The arbitrator may, in the
					 event of nonappearance, decide the issue on the basis of the evidence before
					 it. Either party may be represented by an attorney.
(c) Except as provided in sections
					 325-6.6(c)
					 and
					 325-6.7(c) 
					 of this Subpart, the arbitrator will only consider those objections to requests
					 for reimbursement which have been timely served on the health insurer in
					 accordance with section
					 325-6.4 
					 of this Subpart, and documents supporting objections to requests for
					 reimbursement which have been timely served on the health insurer in accordance
					 with section
					 325-6.4(a)
					 and (f)  of this Subpart or supporting the
					 request for reimbursement, which have been timely served on the carrier in
					 accordance with section
					 325-6.2 
					 of this Subpart. Any party wishing to serve new or additional objections or
					 documents based solely on newly discovered evidence after the expiration of the
					 time for serving objections or documents must serve such objections or
					 documents on the dispute forum within 14 days after the date of acknowledgment
					 of the completed request for arbitration from the dispute forum, in the case of
					 desk hearings, or no later than 14 days prior to the scheduled date of an oral
					 hearing. The new or additional objections or documents must be accompanied by
					 an affidavit substantiating why such objections or documentation could not have
					 been made or discovered and served within the prescribed time period, together
					 with proof of service of all additional objections or documents, including the
					 supporting affidavit, on the other party. The arbitrator may, in his or her
					 sole discretion, consent in writing to the service of new or additional
					 objections or documentation and consider such new or additional objections or
					 documents when making his or her decision if he or she determines that special
					 circumstances exist whereby such evidence could not have been previously
					 discovered and consideration of the new or additional objections or
					 documentation in the interests of justice is warranted. Where payment is made
					 by the carrier after the request for arbitration has been served, the carrier
					 must submit proof of payment. If it is determined by the arbitrator that full
					 payment has been made but such payment was not timely, the arbitrator must
					 award the health insurer any filing fees paid by it, in accordance with this
					 section.
(d) A record of such oral
					 hearing shall not be required. Any party requesting a readable, viewable or
					 audible record of an oral hearing shall inform the other party and the
					 arbitrator of such intent, shall make the necessary arrangements and pay the
					 cost thereof directly to the person or agency making such record. The
					 arbitrator and any other party or parties to the arbitration shall be entitled
					 to view or hear the record and shall be entitled to a copy of such record upon
					 payment of the cost of a copy of such record.
(e) The arbitrator may postpone or adjourn
					 any hearing upon request of a party or upon the arbitrator's own motion. Each
					 party may cause one adjournment without the payment of an adjournment fee if
					 the adjournment request is received by the dispute forum at least two business
					 days prior to the scheduled arbitration. There shall be an adjournment fee of
					 $50 payable to the dispute forum by the party requesting any subsequent
					 adjournment if such request is received by the dispute forum at least two
					 business days prior to the scheduled arbitration. An adjournment fee of $100
					 shall be payable to the dispute forum by the party causing the adjournment
					 within two business days or less prior to the scheduled hearing. Such fees
					 shall be used to defray the cost of administration of the dispute
					 forum.