N.Y. Comp. Codes R. & Regs. tit. 12 § 327.3

Current through Register Vol. 46, No. 45, November 2, 2024
Section 327.3 - Notice of carrier's objections to bills and hospital's request for arbitration
(a)
(1) A carrier objecting to any bill for hospital care or for services performed by a hospital shall notify the hospital in writing that the bill is not being paid and explain the reasons for nonpayment within 45 days after the bill has been submitted in accordance with section 325-1.24 or 325-1.25 of this Title. The notification shall contain the name, telephone number, facsimile transmission number and email address, if available, of a contact person to whom the hospital may address any inquiry regarding the carrier's objection to the bill. The carrier shall set forth the specific basis for its nonpayment of the bill and explain in detail the reasons supporting its objections. Any objection which sets forth the specific basis for nonpayment but does not explain in detail the reasons supporting the objection shall not be considered sufficient notification in writing for purposes of this section.
(2) Notwithstanding the provisions of paragraph (1) of this subdivision, in any case the submission of a notice of controversy and notice of treatment issue or bill dispute in the format prescribed by the chair and service of the notice upon the hospital within such 45-day period shall be deemed to be a notification in writing explaining the reasons for nonpayment with respect to any legal objections raised therein. In lieu of providing such notices to the hospital, the carrier may send the hospital a sufficiently detailed written explanation raising legal objections to the bill. If the carrier has timely submitted such notices with the chair and served a copy of the notice upon the hospital or sent the hospital a sufficiently detailed written explanation raising legal objections to the bill, the carrier shall notify the hospital in writing that the bill is not being paid and explain the reasons for nonpayment, in the same manner as set forth in paragraph (1) of this subdivision, within 30 days after all questions duly and timely raised with respect to the carrier's liability for such bill have been finally determined adversely to the carrier; provided, however, that the explanation for nonpayment shall not be on the basis of any issues previously adjudicated by the Workers' Compensation Law judge or the board which have been finally determined adversely to the carrier. If the carrier files an application for review of a decision by a Workers' Compensation Law judge, the carrier shall serve a copy of the application for review, together with the prescribed cover sheet (form RB-89) on the hospital simultaneously with its service on all other parties required to be served. The carrier may notify the hospital in writing that it has filed an application for review, in lieu of serving a copy of the application and cover sheet on the hospital.
(3) If the carrier fails to object to a bill in accordance with the provisions of section 325-1.24 or 325-1.25 of this Title and this subdivision, the hospital may request an administrative award in accordance with section 325-1.24 or 325-1.25 of this Title.
(b) Upon receipt of a timely written notification of the carrier's explanation for nonpayment in accordance with subdivision (a) of this section, the hospital may request arbitration by notifying the chair in accordance with the following:
(1) if the carrier has not raised legal objections to the bill, the request for arbitration shall be submitted a minimum of 45 days after the date of the hospital's submission of the bill to the carrier, but no later than 120 days after receipt of notification of nonpayment, or
(2) if the carrier has raised legal issues, the request for arbitration shall be submitted subsequent to the hospital's receipt of the carrier's written explanation for nonpayment but in any event no earlier than 30 days after the date of notice of a final decision by the Workers' Compensation Law judge or the board in favor of the hospital with respect to issues requiring adjudication, and no later than the later of 120 days after either the date of filing of such decision or the date of receipt of the carrier's explanation for nonpayment.
(b) If the hospital wishes to arbitrate, it shall complete and sign the request form for arbitration and forward it to the address specified on such form. The hospital's failure to make a timely request for arbitration shall be deemed a waiver of the right to arbitration; provided, however, that upon application of the hospital, the chair may for good cause excuse the hospital for the delay in filing the request for arbitration and schedule the disputed bill for arbitration.
(c) The hospital's failure to submit a bill to the carrier within 120 days from the last day of the month in which services were rendered shall be deemed a waiver of the right to arbitrate the bill; provided, however, that upon application of the hospital, the chair may for good cause shown excuse the hospital for delay in submitting such bill to the carrier, and schedule the bill for arbitration.

N.Y. Comp. Codes R. & Regs. Tit. 12 § 327.3

Amended, New York State Register April 2, 2014/Volume XXXVI, Issue 13, eff. 4/2/2014