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Appeal Process for Disputed Payment

Last update
December 23, 2022

After a workers’ compensation medical bill is submitted by a provider in New York state, an employer must pay bills within 45 days or notify providers that the bill is not being paid and explain the reasons for non-payment in writing within that same time period.

The Consolidated Laws of New York, in Article 2 Section 13-G, stipulate that improper payment for compliant medical bills requires an appeal from the provider using Form HP-1.

If a payer fails to make timely payment after the Workers’ Compensation Board (WCB) has decided in favor of a provider, providers must file a Request for Judgement of Award.


Form HP-1: Request for Decision on Unpaid Medical Bills

If a provider wishes to request a decision on an unpaid medical bill on Form HP-1, the following conditions must apply:

  • The original bill was submitted on the CMS-1500, UB-04, or C-4 Form;
  1. For help filing CMS-1500 Forms, please refer to daisyBill’s New York Bill Instructions: CMS-1500.
  • The original bill submission was timely and compliant with the appropriate Fee Schedule;
  • A Denial of Claim (C-8.1) has not been received, or, if one has been received, the WCB has ruled in the provider’s favor in regard to the issues raised on the denial form.

Providers must then choose between two types of appeal:

Administrative Award

When a payor has NOT responded to a bill within 45 days or within 30 days of a final decision by the WCB in favor of the provider with the following:

  • Payment; or
  • Form C-8.4; or
  • Written explanation of non-payment;

NOTE: Bills for Ambulance, Audiology, Dental, Durable Medical Equipment, Optometry, Other, Out of State or Pharmacy cannot be submitted for Administrative Award. They must be submitted for Arbitration.

Arbitration 

When a payor HAS responded to bills with a timely (45 days) written explanation of partial or non-payment, Form C-8.4 was filed compliantly, and the parties cannot agree on the appropriate reimbursement value then a provider may request a decision by Arbitration.


Administrative Award

Cause

Appeal Type

Regulations

Timeline

Form

Lack of Response

Administrative Award

Section 13-G Payment of bills for medical care

45 days from submission of the bill or 30 days from the date of a final decision from the WCB.

HP-1 (2/18)

If the payor fails to make payment or notify the provider within 45 days, the provider may notify the Chair in writing that the bill has not been paid and request that an award for payment using Form HP-1.

The request must be received by the Board's Disputed Medical Bill (DMB) Unit within 165 days after the provider has submitted the original bill to the carrier and include a copy of that bill.

When the case is determined in favor of the provider awards may not exceed the established Fee Schedule or part remaining unpaid and the employer will be charged a fee of $50 to be paid into the state treasury.

Submission

Send completed Form HP-1 and attachments to:

NYS Workers' Compensation Board

PO Box 5205

Binghamton, NY 13902-5205

If the bill is determined to be due and owing, the Board may include interest of 1.5% per month payable to the provider; calculated from 45th day after bill rendered or 30th day after determination against employer, whichever is later.


Arbitration

Cause

Appeal Type

Regulations

Timeline

Form

Incorrect Payment Amount

Arbitration

Section 13-G Payment of bills for medical care

45 days from submission of the bill or 30 days from the date of a final decision from the WCB but no more than 120 days from receipt of the notification of non-payment.

HP-1 (2/18)

If the employer has provided an explanation in writing but the appropriate payment amount remains disputed, the provider may request arbitration to decide the payment value. The value is then decided through a single arbitrator process.

The WCB Chair appoints a physician who is “a member in good standing of one or more recognized professional associations representing its respective profession” to determine the value of the services rendered based on the appropriate fee schedules.

For an arbitration appeal, New York requires providers to submit the following supporting documentation with Form HP-1:

Form

Required Supporting Documentation

HP-1 (Arbitration)

Copy of the carrier's payment explanation, including a copy of Form C-8.4, must be attached. 

Submission

Send completed Form HP-1 and attachments to:

NYS Workers' Compensation Board

Medical Director's Office Riverview Center, Suite 195, 150 Broadway

Menands, NY 12204

Decisions rendered under the single arbitrator process shall be conclusive upon the parties as to the value of the services in dispute. There are no filing fees.

If the bill is determined to be due and owing, the Board may include interest of 1.5% per month payable to the provider; calculated from 45th day after bill rendered or 30th day after determination against employer, whichever is later.


HP-J1 Form: Request for Judgment of Award

If an employer fails to pay an Administrative Award or Arbitration Decision within 30 days, providers may file the Form HP-J1 to request enforcement of the judgment for the award. Waiting 60 days is recommended to allow for carriers' billing & payment cycles.

Cause

Appeal Type

Regulations

Timeline

Form

Non-Payment of Award or Decision

Judgement of Award

Section 54-B Enforcement on failure to pay award or judgment

Minimum of 30 days from Award or Decision, but 60 days is recommended.

HP-J1 (7-08)

NOTE: The consent to file and certified copy of the decision that awards compensation must be filed with the appropriate county clerk's office within 30 days following the execution of the document.


Appeals in Court

Further appeal is outlined in Article 2, Section 23: Appeals which stipulates that any decision by the board may be further challenged in court:

  • Any party in interest may file an application for modification or rescission or review of an award or decision within 30 days. The board will then render its decision upon such application in writing.
  • Any party in interest may then file an appeal with the Third Department of the Supreme Court within 30 days of either notice of the board’s decision or after notice of an administrative redetermination review decision by the chair.

For more on workers’ compensation billing, please refer to daisyBill’s New York Billing Guide.


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