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12 CRR-NY 325-5.5NY-CRR

STATE COMPILATION OF CODES, RULES AND REGULATIONS OF THE STATE OF NEW YORK

TITLE 12. DEPARTMENT OF LABOR

CHAPTER V. WORKERS' COMPENSATION

SUBCHAPTER C. MEDICAL PROVIDER AUTHORIZATION

PART 325. MEDICAL AND SURGICAL CARE AND TREATMENT

SUBPART 325-5. COMPUTER MATCH BETWEEN HEALTH INSURERS AND WORKERS' COMPENSATION CARRIERS

12 CRR-NY 325-5.5

325-5.5 General procedure for data-matching.

(a) Format of requests for computer searches.

Health insurers participating in the match program shall submit requests for computer searches in a technological format prescribed by the chair. Such requests for computer searches shall include the claimant’s social security number, if known, last name, initial of first name or first name, sex, date of birth, date of treatment, or date of accident, if known, and such other qualifiers permitted or required by the chair that would establish the identity of the claimant as the person whose payments were covered by the health insurer.

(b) Time limitations.

The date of treatment or accident submitted by the health insurer will be matched against the date of accident contained in the board’s file. If the date of treatment submitted by the health insurer is within 360 days of the date of accident contained in the board file, the health insurer will receive a match on this time limitation criterion. A match on the time limitation criterion is required for all full matches.

The board will compare all information supplied by the health insurer against individually identifiable information contained in board case files. When there is an identity of information between the information supplied by the health insurer and the individually identifying information contained in a claimant’s case file of a quality and quantity to create a reasonable basis for the board to determine that they are the same person, based on criteria set by the chair that would establish the identity of the claimant as the person whose payments were covered by the health insurer, the board shall notify the health insurer that there is a full match with respect to the claimant. A match on the time limitation criterion is required for all full matches.

(d) Partial matches.

The board will compare all information supplied by the health insurer against individually identifiable information contained in board case files. When there is some identity of information between the information supplied by the health insurer and the individually identifying information contained in the claimant’s case file, but such identity of information is not of a quality or quantity to create a sufficient reasonable basis for the board to determine that they are the same person, based upon criteria set by the chair that would establish the identity of the claimant as the person whose payments were covered by the health insurer, the board shall notify the health insurer that there is a partial match with respect to the claimant.

(e) Match situations.

(1) Full match. When there is a "full match,'' the board will provide the health insurer with the following information:

(i) the workers' compensation case number;

(ii) a description of the injury or illness (if and as available in the board's computer database);

(iii) the workers' compensation carrier's identification number (carrier code);

(iv) the workers' compensation carrier's case number (if and as available in the board's computer database);

(v) a designation as to whether the carrier accepted the case by filing a C-669 (if and as available in the board’s computer database);

(vi) a designation as to whether ANCR has been established (if and as available in the board's computer database); and

(vii) a designation as to whether the case is open or closed (if and as available in the board's computer database).

If there is a full match, the health insurer will be placed on notice for future hearings and decisions. A health insurer will only be placed on notice for future hearings and decisions in cases where there is a full match.

(2) Partial match. When there is a "partial match,'' the Workers' Compensation Board will provide the health insurer with the following information:

(i) the workers' compensation carrier's identification number (carrier code);

(ii) the workers' compensation carrier's case number (if and as available in the board's computer database); and

(iii) identification of the fields that failed the "full match'' process.

In such a situation, the health insurer shall not receive copies of hearing and decision notices and shall not be provided with the claimant's workers' compensation case number, a description of the injury or other individually identifiable information.

(3) No match. A "no match'' occurs when sufficient matching data is not available for either a full match or a partial match. Where there is a "no match,'' no information is provided to the health insurer on that record or request.

(f) Return of requests for computer searches.

The board shall process a health insurer's initial request for computer searches and notify the health insurer of the information on "full'' and "partial'' matches. The board will make every effort, barring unforeseen circumstances, to respond to and return the search request of the health insurer within 30 days of receipt of the search request.

(g) Availability of information in board files.

(1) When a health insurer has been notified of a “full match'' pursuant to paragraph (e)(1) of this section and the workers’ compensation claim has been established by a board finding of ANCR or, if technologically feasible, by acceptance of a claim, the health insurer shall be eligible to access the board’s electronic case file for such claim. A health insurer or its HIMP agent must execute an agreement prescribed by the board to be eligible to access the board’s electronic case files. Failure of a health insurer or its HIMP agent to comply with the terms of such agreement or with board rules, regulations, or policies governing the board’s electronic case files shall be grounds, following a hearing, for the chair to prohibit access to the board’s electronic files. In addition, if the files are not available electronically, such health insurer may make a request in writing to the board for any information in the board files as may be relevant to any bill that has been paid by such insurer or health benefits plan. Such requests shall be submitted to the Workers' Compensation Board at an address designated by the chair.

(2) Upon receipt of a written request by a health insurer pursuant to paragraph (1) of this subdivision, the board files shall be reviewed by board personnel to determine which, if any, documents, reports, records and/or other materials contained therein are relevant and/or necessary to the request for reimbursement made by the health insurer. The cost for review of board files by board personnel shall be borne by the health insurer in accordance with section 325-5.6 of this Subpart. Copies of all such documents, reports, records and/or other materials contained therein determined to be relevant and/or necessary by board personnel shall be made available to the health insurer requesting such information, provided, however, that no copies of such information shall be made available to a health insurer with respect to any compensation claim which has been closed without findings of accident, notice and causal relationship. In such cases where the case has been closed without findings of accident, notice and causal relationship, the board shall so advise the health insurer in writing. The costs of photocopying documents, reports, records and/or other materials from board files shall be borne by the health insurer in accordance with section 325-5.6 of this Subpart.

(h) Age of claims to be submitted.

Requests for computer searches must be submitted to the board within three years of the date of payment for services rendered by the health care provider.

12 CRR-NY 325-5.5

Current through August 31, 2021

End of Document

IMPORTANT NOTE REGARDING CONTENT CURRENCY: The "Current through" date indicated immediately above is the date of the most recently produced official NYCRR supplement covering this rule section. For later updates to this section, if any, please: consult editions of the NYS Register published after this date; or contact the NYS Department of State Division of Administrative Rules at [email protected]. See Help for additional information on the currency of this unofficial version of NYS Rules.