N.Y. Comp. Codes R. & Regs. Tit. 12 § 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.
(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.
Notes
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