N.Y. Comp. Codes R. & Regs. tit. 12 § 325-6.12

Current through Register Vol. 46, No. 25, June 18, 2024

Section 325-6.12 - Decisions of the arbitrator; awards; interest

(a) The arbitrator shall make a decision in writing no later than 30 days after completion of a hearing. The decision shall contain a dollar amount of an award or a denial of the claim, and shall specify the basis of the decision on the form prescribed by the dispute forum for such purpose. The decision may include any stipulation made by the parties, including stipulations as to payment of fees. The decision shall be delivered to each party in accordance with section 325-6.15(b) of this Subpart.

(b) In the event the arbitrator's decision is in favor of the health insurer in the full amount requested, the amount of the award shall be increased by the amount of any filing fee, or any additional fee paid by the health insurer including any fee for manual searches as provided in section 325-5.6(b) of this Part, except attorney's fees, for oral hearings. In the event the claim for reimbursement is denied in full, the arbitrator shall make an award in favor of the carrier for any filing fees or additional fees, except attorney's fees, paid by the carrier. In all other cases, the arbitrator shall, in his or her discretion, determine whether such fees shall be allocated and the manner of such allocation provided, however, that in all cases in which the arbitrator's decision is based in whole or in part upon objections or documents received and accepted by the arbitrator as newly-discovered evidence pursuant to section 325-6.11(c) of this Subpart, and is entirely or partly in favor of the party which served the objections or documents untimely, any filing fees shall be chargeable to such party in whole or in part. In any such case the arbitrator, when allocating such fee, shall consider the extent to which the other party may have been prejudiced by the prevailing party's failure to serve the objections or documentation in a timely manner. If payment is made to the health insurer after the time within which the carrier was required to object or making payments has expired and the carrier submits proof of payment after the health insurer has served a request for arbitration, the arbitrator shall make an award to the health insurer for any filing fees paid by it.

(c) If the arbitrator determines that the carrier's objection to or non-payment of the reimbursement or the health insurer's request for arbitration was frivolous or was not made in good faith, he or she may impose in his or her discretion a penalty of no greater than $1,000 against the party whose position was frivolous or not made in good faith. Such determinations shall be limited to instances where the objection to non-payment or request for arbitration had no basis in fact, or was not warranted by existing law or good faith argument for the extension, modification, or reversal of existing law. Any penalty shall be issued in the form of an arbitrator award payable to the opposing party by the party whose position was deemed frivolous or not made in good faith.

(d) Within 15 days of the date of the arbitrator's decision, either party may serve a request for reconsideration by serving a written request for reconsideration on the opposing party and by serving two copies of the written request with proof of service of the request for reconsideration and an additional filing fee of $150 on the dispute forum. The party seeking reconsideration shall have the burden of establishing that the original decision is incorrect as a matter of law or fact. The party opposing reconsideration shall have fifteen days to serve its written response on the serving party and two copies on the dispute forum. Such reconsideration shall be conducted by the arbitrator who issued the underlying decision. The arbitrator shall issue a written decision on the request for reconsideration in accordance with subdivision (a) of this section. The arbitration decision, including payment of arbitrator's awards and reimbursement of filing fees, shall not become final for purposes of subdivision (e) of this section during the pendency of a request for reconsideration and shall be stayed during the pendency of such request for reconsideration. If the arbitrator determines that the request for reconsideration was frivolous, he or she may impose in his or her discretion a penalty of no greater than $1,000 against the party seeking reconsideration. The proceeds of the penalty shall be paid in equal parts to the dispute forum and the other party. In no case shall the arbitrator impose the additional filing fee for a request for reconsideration on the party opposing reconsideration.

(e) Awards shall be paid to the prevailing party no later than 30 days after service of the decision upon the parties. Any awards remaining unpaid after said 30-day period shall draw simple interest from 30 days after the making of the award at the rate provided in section 5004 of the Civil Practice Law and Rules.

N.Y. Comp. Codes R. & Regs. Tit. 12 § 325-6.12

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