Statutes, codes, and regulations
New York Codes, Rules and Regulations
Title 12 - DEPARTMENT OF LABORChapter V - Workers' CompensationSubchapter C - Medical Treatment and CarePart 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

N.Y. Comp. Codes R. & Regs. tit. 12 § 325-6.11

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Current through Register Vol. 46, No. 25, June 18, 2024
Section 325-6.11 - Hearing of cases
(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.

N.Y. Comp. Codes R. & Regs. Tit. 12 § 325-6.11

Adopted New York State Register April 6, 2016/Volume XXXVIII, Issue 14, eff.6/1/2016