N.Y. Comp. Codes R. & Regs. Tit. 12 §§ 325-6.1

Current through Register Vol. 46, No. 45, November 2, 2024

Section 325-6.1 - Definitions

As used in this Subpart:

(a)Acceptance of claim shall mean the filing of notice in the format prescribed by the chair of the carrier's acceptance of a claim of benefits.

(b)Accident shall include both an accident arising out of and in the course of employment and an occupational disease. In the case of occupational disease, date of accident, where used in this Subpart, shall mean date of disablement.

(c)ANCR shall mean accidental injury or occupational disease, notice and causal relationship.

(d)Board shall mean the Workers' Compensation Board, and in the case of board determinations shall include those made by a member or panel of the board, by a Workers' Compensation Law judge, conciliator or by the full board.

(e)Carrier shall mean a self-insured or uninsured employer, or workers' compensation insurance carrier as defined in section 300.1(a)(7) of this Title, or special fund created by the Workers' Compensation Law for payment of workers' compensation claims, but shall not include the uninsured employers' fund.

(f)Chair shall mean the chairperson of the Workers' Compensation Board of the State of New York.

(g)Dispute forum shall mean the American Arbitration Association or such other private arbitration association or forum for alternative dispute resolution designated by the chair and posted on the board's website to arbitrate disputed requests for reimbursement.

(h)Health insurer shall mean a health insurer, health benefits plan or other payor of health benefits as defined in section 13 (d) of the Workers' Compensation Law, when acting directly or through a HIMP agent.

(i)HIMP means the Health Insurance Matching Program authorized by section 13 (d) and (h) of the Workers' Compensation Law and refers to processes established by the board to assist a health insurer in reimbursement from a carrier for payments made for medical and/or hospital services for or on behalf of an injured employee, and for arbitration of disputed claims for reimbursement.

(j)HIMP agent shall mean a person or entity that is designated and authorized by a health insurer to submit information for matching under this Subpart and to seek reimbursement from a carrier under this Subpart on behalf of the health insurer. A HIMP agent must execute a written agreement, prescribed by the chair, between the HIMP agent, the health insurer and the board and file such agreement with the board. In addition a HIMP agent must comply with all laws, regulations and policies applicable to health insurers as set forth in Workers' Compensation Law section 13(d) and (h), and this Part. Failure to comply with all terms of such written agreement or such other agreements with the board or with all applicable laws, regulations, and policies is grounds for termination of an individual or entity's status as HIMP agent and to preclude its participation in and rights under Workers' Compensation Law section 13(d) and (h), and this Part.

(k)Provider shall mean a physician, hospital, physical or occupational therapist, podiatrist, chiropractor, psychologist or other health provider to whom payment has been made by the health insurer.

N.Y. Comp. Codes R. & Regs. Tit. 12 §§ 325-6.1

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