N.Y. Comp. Codes R. & Regs. tit. 12 § 325-6.3

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

Section 325-6.3 - HIMP-1 filing procedures and documentation

(a) A health insurer requesting reimbursement must serve the HIMP-1 form, or other form or format for request prescribed by the chair, on the carrier before such request may become eligible for arbitration. The HIMP-1 form may only be served on the carrier after the health insurer is notified of a "full match'' pursuant to Subpart 325-5 of this Part.

(b) The following time limitations shall govern requests for reimbursement by a health insurer:

(1) The health insurer must submit the data concerning medical treatment to the board for a match or have received a full match in connection with the same workers' compensation claim within three years of the date of payment for services rendered by the health care provider to be eligible for arbitration.

(2) A health insurer must serve a HIMP-1 form on the carrier, in accordance with section 325-6.15(a) of this Subpart, within one year of the latest date of the following:

(i) the acceptance of the claim or the establishment of ANCR to the particular body part or disease in question;

(ii) the date the board notifies the health insurer of the full match pursuant to Subpart 325-5 of this Part;

(iii) the date of payment for services; or

(iv) the effective date of this Part.

(c) The health insurer must complete all information required on the HIMP-1 form and must serve the completed form on the carrier, together with copies of all provider bills and/or other documents which form the basis for the request for reimbursement. The provider bills and/or other documents shall include the name of the person for whom treatment was rendered, a diagnosis with applicable ICD code(s), the date(s) of treatment or hospitalization, an itemization of the services rendered and the corresponding charges with standardized billing codes, and in the case of hospital bills, the nature of the treatment for which the claimant was hospitalized. The bills or supplemental documentation must also identify the diagnosis and/or treatment codes, including CPT codes or DRG codes where applicable, utilized by the health insurer to determine the amount of payment to the provider. All requests for reimbursement served on the carrier after establishment of ANCR must contain a form C-23, C-18, C-67 or any other notice of decision issued by the board establishing ANCR to the part of the body or for the condition for which the health insurer made payment to the provider, if such form was available to the health insurer at the time form HIMP-1 is served. The name of the claimant (or, in the case of death, the decedent) on the notice of decision must be the same as that of the person on whose behalf the health insurer made the payments for which reimbursement is being sought. All requests for reimbursement served on the carrier before establishment of ANCR must contain documentation indicating acceptance of the claim. The name of the claimant (or, in the case of death, the decedent) on such document must be the same as that of the person on whose behalf the health insurer made the payments for which reimbursement is being sought.

(d) A health insurer may submit more than one treatment for reimbursement on a single HIMP-1 form so long as the health insurer provides separately the date(s) of treatment or hospitalization, an itemization of the services rendered and the corresponding charges, and in the case of hospital bills, the nature of the treatment for which the claimant was hospitalized for each treatment or hospitalization.

(e) Reimbursement to a health insurer by a compensation carrier under Workers' Compensation Law section 13(d), shall, except as otherwise provided in section 13(d), be for an amount that is equal to the amounts actually expended by the health insurer for the medical and hospital services, provided that such amount is within the limits of the fee schedules established pursuant to Workers' Compensation Law, sections 13(a), 13- k(2), 13-l(2), and 13-m(3) or, in the case of inpatient hospital bills, the rate of payment for inpatient hospital services established pursuant to the provisions of the Public Health Law. If the amount of reimbursement claimed by the health insurer differs from the amounts expended by the health insurer and/or the amount actually paid to a provider differs from the amount set forth in the provider's bill, the health insurer must explain the basis for the difference, and what the difference represents.

(f)Medical records.

(1) A carrier, through its attorney, may request from the treating health care provider such medical records associated with the treatment paid by the health insurer and submitted for reimbursement under this Subpart that are necessary for the carrier to manage the related workers' compensation claim. The treating health care provider shall provide such records to the carrier, within 14 days of the request. Failure to comply with such request may be grounds for action pursuant to section 13(d) of the Workers' Compensation Law.

(2) A carrier may issue a subpoena duces tecum to the treating health care provider in accordance with Workers' Compensation Law section 119 to compel production of medical records set forth in paragraph (1) of this subdivision.

(3) The health insurer and carrier shall not unreasonably refuse to modify filing deadlines to allow time for a carrier to receive medical records, where necessary for resolution of a reimbursement request, as provided in section 325-6.16 of this Subpart. Requests for medical records shall not be used by a carrier solely to delay reimbursement or arbitration of a request for reimbursement.

N.Y. Comp. Codes R. & Regs. Tit. 12 § 325-6.3

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