New York State Workers' Compensation Board Glossary

Glossary

A

Abey an Issue (also Held in Abeyance)

To postpone a decision on an issue in a case until a later date, when it is expected that additional pertinent information may or will be available.

Accepted Claim

A claim for which an insurer has accepted liability.

Accident

An event, arising out of and in the course of employment, that results in personal injury to a worker.

Accident Date

Refers either to (a) the date the accident is deemed to have occurred, or (b) the date of onset assigned to an occupational disease. For eClaims, the IAIABC refers to this as “Date of Injury.”

Related eClaims Data Element(s) (DN):

DN0031 (Date of Injury)

Accident Description

Text that relates and describes an accident, often segmented into sections that respond to a series of questions about the accident.

Related eClaims Data Element(s) (DN):

DN0038 (Accident/Injury Description Narrative)

Accident, Notice and Causal Relationship (ANCR)

Minimal conditions that must be met before financial responsibility can be assigned to a claim for workers' compensation. Specifically, it must be established that (a) a work-related accident covered by the Workers' Compensation Law (WCL) has occurred; (b) following the accident, the injured worker has notified their employer within the time limit required by the WCL; and (c) a causal relationship exists between the accident and the resulting injury or disability.

Accident Time in Shift

Time when accident occurred, relative to the beginning of the injured worker's shift.

Accident Time of Day

Time of day when accident occurred.

Related eClaims Data Element(s) (DN):

DN0032 (Time of Injury)

Acknowledgement Date

The date a medical bill is accepted by the payer. Payers must accept an electronic medical bill from an XML submission partner when it is transmitted using EDI or another format agreed upon with the XML submission partner. The acknowledgement date is found in field 19 of the CMS-1500 form.

Acknowledgement Record

An electronic reply sent by the Board to acknowledge receipt of a First Report of Injury (FROI) or Subsequent Report of Injury (SROI). The acknowledgment record will indicate if the FROI or SROI was accepted or rejected. It will provide the Jurisdiction Case Number (JCN) to the claim administrator for First and Subsequent Reports of Injury that are accepted. When a transaction is rejected, the acknowledgment record will provide the reasons for the rejection. Flat file submitters will receive an acknowledgment record via flat file. Web submitters will receive an acknowledgement record via an immediate confirmation message.

Acquired Claim

A claim that was previously administered by a different claim administrator. The acquisition of a claim is a claim event that must be reported to the Board.

Active Duty/Service

For the purposes of NYS Paid Family Leave, the deployment of a member of the U.S. Armed Forces overseas.

Adjourn (a Hearing)

To put off or suspend until a future time, without issuing a decision. However, a Notice of Decision must still be issued to continue the hearing.

Adjudication

The Board's process of holding hearings on claims that are challenged and then making determinations on whether those claims are compensable. Any further issues that arise in these claims cannot be handled informally.

Administrative Decision

A decision issued to the parties in a claim to memorialize findings and awards not in dispute.

Adult Career and Continuing Education Services-Vocational Rehabilitation (ACCES-VR)

A unit of the NYS Education Department that evaluates vocational rehabilitation needs and sometimes provides vocational rehabilitation services to (among other groups) referred workers' compensation claimants.

Age at Injury

Claimant's age on the date of accident or the onset of occupational disease (as officially established by the Board).

Related eClaims Data Element(s) (DN):

DN0052 (Employee Date of Birth)

Aggregate Trust Fund (ATF)

A trust fund established under Section 27 of the Workers' Compensation Law to ensure the payment of workers' compensation benefits in claims involving death, permanent total disability, and the loss of major members. In the case types above, a private insurer is required to pay, and, under certain circumstances, a self-insured employer is permitted to pay the actuarial value of a claimant's future compensation payments into the fund. Upon such payment, the insurer or the self-insured employer are discharged from future liability to the claimant for compensation or death benefits.

Amenable

Subject to, as in "The entity is subject (or amenable) to a requirement of the Workers' Compensation Law."

Appeal

A legal action taken by one of the parties in the Appellate Division, Third Department, to reverse or amend a decision or direction made by a Board panel or the Chair of the Workers' Compensation Board.

Apportionment

A proportionate division of all or part of the benefit costs in a case between two or more injury claims for the same claimant, based on an evaluation of the relative contribution that the injuries have made to the claimant's permanent disability. Apportionment can also occur in a case when a claimant has one injury claim but has other injuries unrelated to their injury claim due to a prior injury outside of work.

Arising Out of and In the Course of Employment (ACOE)

Two necessary conditions that must be met to establish a work-related accidental injury. An injury that “arises out of employment” is one that results from a hazard of the employment, while an injury “in the course of employment” is one that occurred at a time, place, and under circumstances related to the employment.

Assembled Case

A case/claim that has the minimum required information, which includes: the claimant's name and address, employer name and address, and an indication of a work-related injury or illness.

Attachment

Any document that is not a Board form and arrives together with a Board form.

Attorney

A lawyer. Attorneys often represent injured workers, insurers, or employers in workers' compensation cases.

Attorney Fees (Claimant's)

Fees approved by the Board for claimant attorneys in workers' compensation cases. Under Section 24 of the Workers' Compensation Law, no claims for services or supplies are enforceable unless approved by the Board, and, if approved, such claims become a lien upon the compensation awarded.

Average Wage

An eClaims data element reported on the Subsequent Report of Injury (SROI). It is the statutory Average Weekly Wage of the claimant. The Average Wage must be calculated using the proper multiple as defined by WCL Section 14 and using the instructions on the Employer's Statement of Wage Earnings (Form C-240). Wages from concurrent employment as defined by Section 14-6 should be included. In the Claims Information System (CIS) FROI/SROI tab, the Average Wage is shown under Wages/Salary on Latest Values as “Calculated Wage.”

B

Benefit Mortality

Termination of long-term benefits (e.g., permanent total disability, non-schedule permanent partial disability, death benefits). Long-term benefits cease mainly for the following reasons: (a) claimant's/recipient's death; (b) Section 32 Waiver agreement; (c) claimant's return to full-time employment; (d) loss of eligibility (e.g., remarriage of widow/widower). Anticipated benefit mortality rates (mortalities per year) affect the present value of such benefits.

Benefit Type Code (BTC)

A code that identifies the benefit being paid by the claim administrator (e.g., 050 – Temporary Total). For eClaims R3.1, the BTCs accepted by the Board are listed in the Valid Value Detail Page 1 sheet of the Edit Matrix Table.

Related eClaims Data Element(s) (DN):

DN0085 (Benefit Type Code)

Board-Authorized Provider

A health care provider the Board has approved to treat workers who become injured or ill on the job.

Board Customer

Claimant and/or employer, formerly referred to as party of interest.

Board Panel

A panel, usually made up of three Workers' Compensation Board members (at least one of whom must be a lawyer), that reviews requests to amend decisions made by Workers' Compensation Law Judges.

Bonding

A qualifying event for Paid Family Leave, in which the employee takes paid leave to care for a newly born, adopted, or fostered child.

Bureau of Labor Statistics (BLS)

Division within the U.S. Department of Labor most directly involved with collecting and disseminating data regarding workers' compensation and workplace safety.

C

Calendar

A list of the cases scheduled to be heard on a given date at a specific part at a district office or hearing point.

Cancel (a Case)

An action by the Board to nullify indexing or assembly in one of these scenarios: (a) when it's identified there are two case numbers for a single claim (b) when it's identified that a claim should not have been assembled.

Carrier

See Insurance Carrier

Carrier Catastrophe Number

A sequential number (beginning with 1) assigned by carriers to catastrophes (any accident resulting in two or more reported claims) occurring under a particular policy.

Carrier Code

A seven-character code that identifies a specific insurance carrier. These codes begin with “W” for workers' compensation and “B” for disability. Carriers that write both policy types are assigned one of each code.

Case

A reported work-related injury or illness that has been assembled and assigned a case number by the Board.

Case Number

The number assigned to a workers' compensation claim. The case number structure is eight characters beginning with an alpha character, followed by seven numeric characters. For example, G1234567.

Volunteer ambulance workers' cases begin with AA, followed by six numbers (e.g., AA123456).

Volunteer firefighters' cases begin with FA, followed by six numbers (e.g., FA123456).

The WCB case number does not designate the district or year the case was created. For eClaims purposes, the Jurisdiction Claim Number (JCN) is the WCB case number.

Related eClaims Data Element(s) (DN):

DN0005 (Jurisdiction Claim Number)

Cause of Accident

Hazardous object, substance or condition that directly contributed to the occurrence of an accident.

Cause of Injury

An eClaims data element that indicates the code corresponding to the cause of injury based on information the claim administrator has from the employer and other sources at the time of reporting.

Related eClaims Data Element(s) (DN):

DN0037 (Cause of Injury Code)

Claim

A request for workers' compensation or disability benefits.

Claim Adjustment Reason Codes (CARC)

Codes used by payers to communicate to a provider that an adjustment (most commonly a reduction) was made to the amount paid for a claim or service line of a medical bill. Typically, CARC codes will be found on an Explanation of Benefits/Explanation of Review (EOB/EOR). The non-profit standards organization X12 develops and maintains industrywide, standardized CARC codes under EDI standards and XML schemas that drive business processes. CARC codes are required to be entered on the Notice of Objection to a Payment of a Bill for Treatment Provided (Form C-8.1B) and Notice to Health Care Provider and Claimant of an Insurer's Refusal to Pay All (or a portion) of a Medical Bill Due to Valuation Objection(s) (Form C-8.4); and should be identical to the ones on the corresponding EOB/EOR sent to the provider.

Claim Administrator

The organization that administers a workers' compensation claim. A claim administrator can be an insurer, a licensed third-party administrator, a self-insured employer, a self-insured group trust or a guarantee fund. In eClaims, DN0187 (Claim Administrator FEIN) is reported on the First Report of Injury/Subsequent Report of Injury (FROI/SROI) transaction and decoded to the W number for the insurer/self-insured employer or T number for the third-party administrator as listed in the Claims Information System (CIS) Master ID File.

Related eClaims Data Element(s) (DN):

DN0187 (Claim Administrator FEIN)

Claim Event

A business circumstance in the life of a claim that must be reported to the Board. Examples of claim events are changes in data elements, payment of awards, and suspension of payments to a claimant.

Claim Administrator Claim Number (CACN)

An alphanumeric string identifier assigned by an insurer to a claim for their own records and in reports to ratemaking organizations (e.g., the New York Compensation Insurance Rating Board). Used by the New York Compensation Insurance Rating Board and insurers. Formerly known as the Carrier Case Number.

Related eClaims Data Element(s) (DN):

DN0015 (Claim Administrator Claim Number)

Claim Type Code

A code on a First or Subsequent Report of Injury that identifies the current status of the claim (e.g., M – Medical Only). Claim Type Codes are summarized on the eClaims 3.0 Quick Code Reference List and on the eClaims 3.1 Valid Value Detail Page 1 sheet in the Edit Matrix Table.

Related eClaims Data Element(s) (DN):

DN0074 (Claim Type Code)

Claimant

The injured worker or beneficiary who has filed a claim with the Workers' Compensation Board. This could be for workers' compensation benefits, disability benefits, or for a discrimination case (e.g., if a worker has been fired as a result of asking about or filing a workers' compensation or Paid Family Leave claim). (Note that discrimination claims can be filed by someone other than the employee.)

Class Rating

A method for determining an employer's workers' compensation premiums based on the class(es) included in the employer's payroll and the manual rate schedule for the state.

Classification

A term to describe the severity of an injured worker's condition, illness, or loss of use of a body part after the worker has recovered to the greatest extent possible; this is a factor in calculating the amount of compensation.

Classification Code

A system of insurance risk classification based on industrial or occupational categories, supported by the National Council on Compensation Insurance and in use in about 40 states where private insurance is available. The system, which includes several thousand four-digit numeric codes (with more than 700 work classifications in use in New York and most states), is extensively used to identify an employer's ratemaking class(es) and establish basic pricing for workers' compensation insurance.

CMS-1500

The universal claim form used by medical providers to bill the Centers for Medicare and Medicaid Services (CMS) as well as health insurers. The Board mandated the use of the CMS-1500 by health care providers in 2022.

Compensable

Describes claims for which workers' compensation benefits are payable.

Complete Case

For workers' compensation, a case that has an Employer's Report of Work-Related Injury/Illness (Form C-2F), Employee Claim (Form C-3), or First Report of Injury (FROI) plus a CMS-1500 or equivalent present. For Paid Family Leave, a case that has all of the forms filled out and required documentation attached.

Compliance

The function of ensuring that all Board customers adhere to the applicable laws, rules, and regulations in the workers' compensation system.

Conciliation Process

Claim resolution process that provides an expeditious and informal means to resolve issues involving non-controverted claims where the expected duration of benefits is 52 weeks or less without a hearing (e.g., through meetings or telephone conferences). Each claim that is filed shall be reviewed for possible transfer to Conciliation. Failure to reach an agreement through the conciliation process results in the case being scheduled for a hearing.

Concurrent Employment

Employment of one worker in more than one job during the same period. For eClaims, if there is a concurrent employer in a case, all three DNs listed are required. DN0143 (Concurrent Employer Wage) is listed on the FROI/SROI Latest Value tab under “wages/salary.” All three DNs are listed on the SROI Transaction Details – Employer & Insured tab.

Related eClaims Data Element(s) (DN):

DN0141 (Concurrent Employer Name)
DN0143 (Concurrent Employer Wage)
DN0142 (Concurrent Employer Contact Business Phone Number)

Consequential Accident

A second accident resulting from a prior accidental injury that arose out of and in the course of employment, e.g., a claimant who falls down a flight of stairs at home while using crutches because of a leg injury incurred at work.

Continue (a Case)

To complete a hearing on a case without closing the case, leaving additional matters to be resolved at a future hearing.

Continuous Lapse (CL)

An ongoing non-compliance period during which an employer does not have the appropriate insurance policy on file with the Board.

Controverted Claim

A workers' compensation claim that is disputed by the employer or by the employer's insurer. Each side presents its case at a hearing and a judge then makes a decision.

Coverage

The period of time in which a specific entity/location was insured during the policy period.

COVID-19 Quarantine Leave

Job-protected paid leave in the event that a worker or minor dependent child of a worker is subject to a mandatory or precautionary order of quarantine or isolation issued by the state of New York, the Department of Health, local board of health, or any government entity duly authorized to issue such order due to COVID-19.

D

Data Element (DN)

A data element is a single piece of defined information within a transaction. Every data element is assigned a reference number and has a prescribed format. Some data elements must be sent using certain defined values. An example is DN0249 (Accident Premises Code). See IAIABC for more information.

Death/Fatality Benefits

The cash benefits payable to a beneficiary (i.e., a surviving spouse and/or dependent children) when a worker dies from their work-related injury or illness.

Debarment

The official barring of a business from applying for or bidding on New York State public works contracts. Per Executive Order 192, New York State governmental entities are prohibited from entering into any State contract with businesses that are listed on the Debarment Lists maintained by the NYS Office of General Services. Those convicted of a misdemeanor under the Workers' Compensation Law (WCL), and any substantially owned affiliated entity of such person, or those subjected to civil fines, penalties, or a stop-work order under the WCL, are barred for one year from bidding on public works contracts or subcontracts with the State (WCL §26, 52 or 131). There is a five-year ban for felony convictions, or violators of the discrimination provisions of the WCL (WCL §125 or 125-a).

Decision

A document issued to the parties in a claim with findings and awards made or proposed by the Board. See Administrative Decision, Notice of Stipulated Decision, Proposed Decision, Notice of Decision, Reserved Decision, and Memorandum of Decision.

Degree of Disability

A measurement of a worker's disability as a percentage of their loss of capacity. For example, the degree of disability is characterized as total (100%), marked (75%), moderate (50%), or mild (25%), and levels in between.

Delegate (OnBoard)

A person designated by a health care provider to prepare and submit prior authorization requests (PARs) and/or Request for Decision on Unpaid Medical Bill (s) (Form HP-1.0) on their behalf.

Denial

Full denial of a workers' compensation claim by the claim administrator. A claim administrator may file a FROI-04 or SROI-04 transaction indicating the claim is denied in its entirety.

Dependent (in a Death Case)

A person eligible to receive death benefits in a fatal injury case. The regular receipt of contributions by the alleged dependent upon which they rely and need to sustain their customary mode of living constitutes dependency. Surviving spouses and children under age 18 years are eligible for benefits without proving dependency, and other eligible recipients (if dependency is established) may include dependent children over age 18 years, grandchildren, brothers and sisters under age 18, dependent parents, and grandparents.

Related eClaims Data Element(s) (DN):

DN0097 (Dependent/Payee Relationship Code)
DN0425 (Dependent First Name)
DN0426 (Dependent Last Name)
DN0427 (Dependent Date of Birth)

Discrimination Claim

A claim filed by an employee because the employee believes they were fired or retaliated against because they filed or planned to file a workers' compensation claim, testified or planned to testify in a workers' compensation claim, filed or planned to file a disability benefits claim, or filed or planned to file a NYS Paid Family Leave claim.

Disability Benefits Claim

A claim for an off-the-job injury or illness that does not arise out of or in the course of employment, or for pregnancy.

Disability Benefits Insurance

Insurance required by employers to insure employees against illness or injury that occurs off the job. Paid Family Leave insurance coverage is typically provided as a rider under an employer's disability insurance policy.

Disability Benefits Law

Article 9 of the Workers' Compensation Law provides for the payment of benefits to persons out of work because of illness, pregnancy, or disabling accidents not connected with their employment. The Workers' Compensation Board also is the agency responsible for administration of the Disability Benefits Law.

Disfigurement

Serious and permanent disfigurement to the face, head, or neck.

Domestic Partner

A person who is at least 18 years old and is dependent on the employee for support and who is not related by blood to the employee in a way that would bar marriage in New York State. Dependence can be shown by a variety of factors; some examples include common householding, children in common, signs of intent to marry, shared budgeting, and the length of a personal relationship with the employee. A legal relationship is not necessary.

Double Indemnity (also known as Double Compensation)

A duplicate award of either compensation or death benefits made on the grounds that the injured worker, at the time of the accident, was under the age of 18 years and was permitted or suffered to work in violation of the New York Labor Law. The employer alone, and not the insurer, is liable for the additional compensation.

DME PAR

A type of OnBoard prior authorization request (PAR) for durable medical equipment (DME). DME PARs are made in accordance with the new Official New York Workers' Compensation Durable Medical Equipment (DME) Fee Schedule.

Durable Medical Equipment

Assistive devices prescribed by a health care provider, e.g., braces, walkers, wheelchairs, electric beds, etc., for a patient during treatment and recovery from an injury or illness. This equipment is typically non-disposable and can be rented or purchased.

E

Earning Capacity

The ability of a claimant (i.e., one who has suffered a work-related disabling injury) to earn wages in the labor market. In workers' compensation cases, a claimant's earning capacity is determined by actual post-accident earnings, or, in the absence of such earnings, a theoretic wage-earning capacity may be established by the Workers' Compensation Board. In volunteer ambulance worker and volunteer firefighter cases, earning capacity is defined by the law, VAWBL § 3(8) and VFBL § 3(8).

eCase

The Board's web application that enables registered users to view and print documents in the electronic case folder, as well as upload documents to the folder. Users include injured workers, payers, attorneys and licensed representatives, and certain other parties of interest who want to view the files in their claims.

eClaims

The Board's implementation of an electronic claim reporting standard for reports of injury filings. The Board adopted a national standard for claims reporting from the International Association of Industrial Accident Boards and Commissions (IAIABC). The standard uses Electronic Data Interchange, commonly known as EDI, so that data can be transmitted electronically between the Board and its EDI trading partners quickly, efficiently, and cost-effectively.

Edit Matrix Table

The NYS Requirements tables for claims reporting and proof of coverage (POC) that detail the data elements that have edits applied to them and the error codes that are associated with those edits. It provides the language of the error codes that may be returned by the Board in acknowledgments for electronic filings that have been rejected.

Election of Remedies

The right of a claimant (under Section 11 of the Workers' Compensation Law), whose employer was uninsured at the time of the accident, to bring a court action against such employer in lieu of claiming workers' compensation.

Electronic Case Folder (ECF)

The case folder in the eCase application. Each case has an electronic case folder. It holds case-specific information, including party of interest contact information and case-related documents.

Electronic Data Interchange (EDI)

The structured transmission of data between organizations by electronic means.

Element Requirements Table

NYS Requirements tables for claims reporting and proof of coverage (POC) that detail the data elements that must be reported to the Board. The Element Requirements Table indicates which data elements must be reported and details the conditions under which the data elements are required.

Employee Date of Hire

The date an employee began their employment with an employer. In workers' compensation cases, the claim is filed under the employer's workers' compensation coverage. If there have been multiple periods of employment with the same employer, the date of hire would be the beginning date of the current employment period. In eClaims, the employee date of hire is collected on the First Report of Injury (FROI).

Related eClaims Data Element(s) (DN):

DN0061 (Employee Date of Hire)

Employer

A person, partnership, association, corporation, legal representative of a deceased employer, or the receiver or trustee of a person, partnership, association, or corporation, who has persons in employment. Employers are responsible for providing workers' compensation, disability benefits, and Paid Family Leave benefits coverage for their employees, as appropriate, based on the law.

Employer Number

A unique employer identification number assigned by the Board. The employer number is the primary identifier for all employer records and documents and is the preferred means of searching for employer records.

Established/Accepted Claim

A claim where the Board has determined that an injury, condition, or illness is work-related, or the insurer has accepted the injury or illness.

Event Table

A NYS Requirements table that details the claim events that must be reported to the Board. The Event Table provides the time frames for reporting these claim events and the Maintenance Type Codes that are expected.

Exclusiveness of Remedy

Refers to the workers' compensation system's status as the exclusive remedy of an employee against their insured or lawfully self-insured employer. The system is the sole recourse that the employee, and/or their dependents or representatives have against such employers for injuries or death resulting from a work-related accident or occupational disease.

Exhibit

A document submitted for a hearing as evidence. Exhibits can be submitted to the Board by U.S. mail, email, Web Upload, or eCase Document Upload.

Related to eCase Document Upload: Uploaded forms using form ID EXHIBIT or ATTY_CORR are to provide evidence associated for the hearing only: no action will be taken by a claims examiner. These must be uploaded at the time of hearing with a status of "Hearing Set."

Experience Rating

A method for determining an employer's workers' compensation premiums that reflects (a) a comparison of the employer's recent loss experience with the amount the employer would have been expected to pay if it had been an average employer in the same industry with the same payroll, and (b) the credibility or confidence assigned to the employer's loss experience. In practice, insurers assign no credibility to employers with average class premiums below a certain amount (e.g., $5,000/year).

Explanation of Benefits/Explanation of Review (EOB/EOR)

A document that payers must provide to health care providers for each medical bill whenever the payer's reimbursement differs from the amount billed by the provider, or when an original claim is altered or adjusted by the payer.

Extensible Markup Language (XML)

A markup language and file format for storing, transmitting, and reconstructing arbitrary data. It defines a set of rules for encoding documents in a format that is both human-readable and machine-readable.

F

Family and Medical Leave Act (FMLA): A federal law that entitles eligible employees of covered employers to take unpaid, job-protected leave for specified family and medical reasons with continuation of group health insurance coverage under the same terms and conditions as if the employee had not taken leave.
Family Care: A qualifying event for Paid Family Leave in which the employee takes paid leave to care for a family member with a serious health condition.
Family Member: A spouse, domestic partner, child, stepchild, parent, stepparent, parent-in-law, grandparent, or grandchild. Employees may take Paid Family Leave to care for a family member with a serious health condition.
Fatal Error: An error that is received by a claim administrator when they fail to submit a mandatory field (Data Element) on a First or Subsequent Report of Injury transaction submitted to the Board.
Federal Employer Identification Number (FEIN): A nine-digit identification number assigned by the Internal Revenue Service, also frequently referred to as Employer Identification Number (EIN).
First Report of Injury (FROI): A data transaction that occurs early in a workers' compensation claim. The FROI is most commonly the initial report of injury for a claim. It replaced the following Board forms: Employer's Report of Work Related Injury/Illness (Form C-2), Political Subdivision's Report of Injury to Volunteer Firefighter (Form VF-2), Political Subdivision's Report of Injury to Volunteer Ambulance Worker (Form VAW-2), Notice that Right to Compensation is Controverted (Form C-7) and some C-669 forms (when used for data acceptance). A FROI may also indicate the denial of a claim.
Flat File: A data processing file that has no formatting that is transmitted electronically to the Board. The Board receives claims data for specific claims from claim administrators and policy information from insurance carriers in flat files. The flat file transaction must be accepted by the Board to be considered received by the Board. Flat files are usually submitted by large companies that submit high volumes of data.
Freedom of Information Act (FOIA): The federal law concerned with ensuring public access to federal government records, with limited statutory exceptions.
Freedom of Information Law (FOIL): The New York State version (Public Officers Law, Article 6 - commonly referred to as the Freedom of Information Law or FOIL) of the federal Freedom of Information Act. It requires all state and local government agencies to provide public access to all of their records, with limited exceptions. The Board has taken the position that claim information is not subject to FOIL as excepted based on personal privacy considerations.
Fund for Reopened Cases: A fund established to assume liability for additional awards in cases where the application to reopen the case occurs more than seven years from the date of injury and more than three years from the last payment of compensation. The fund is financed through payments in non-dependency death cases and through assessments made periodically against all insurers. This fund has been closed to new claims since 2013.

G

General Employer: A regular or parent employer who makes an employee available to a special employer. The general employer usually exercises indirect control and they, the special employer, or both may be liable for the compensation due to the injured employee.

H

Hearing

Legal proceeding where the parties in a workers' compensation case come before a Workers' Compensation Law Judge to present evidence and resolve disputes in claims for compensation. The Workers' Compensation Law provides that no case may be closed without notice to all parties interested, with all such parties having an opportunity to be heard.

Hearing Point

Board locations for which calendars are prepared and at which hearings are held.

Hybrid Days (also known as Next Business Day Rule)

Refers to the process for counting days when General Construction Law § 25-a applies:

“When any period of time, computed from a certain day, within which or after which or before which an act is authorized or required to be done, ends on a Saturday, Sunday or a public holiday, such act may be done on the next succeeding business day…”

For example, if the rule is that a response is due within 15 hybrid days, and if the 15th calendar day falls on a Saturday, then the last day to respond will be the following Monday. If Monday is a public holiday, then the last day to respond will be Tuesday.

I

Illegally Employed Minor

Decision element possible in a workers' compensation case involving an injured worker who, at the time of the accident, was under the age of 18 years and was permitted or suffered to work in violation of the New York Labor Law. Cases in this category can give rise to double compensation.

In the Line of Duty

Describes injuries incurred to volunteer firefighters or volunteer ambulance workers while working in their volunteer capacity. Injuries to volunteer firefighters or volunteer ambulance workers are deemed to be "in the line of duty" if incurred at a fire/ambulance service site or in necessary travel to and from such a site. Injuries or illnesses also are "in the line of duty" if they result from hazards and exposures associated with the volunteer's service (e.g., while at a firehouse, hospital, etc.). “In the line of duty" is used for volunteer firefighters and ambulance workers in the same sense as "arising out of and in the course of employment" is for employees.

Incomplete Case

A case that does not have a First Report of Injury (FROI) or Employee Claim (Form C-3) plus a CMS-1500 or equivalent present in the file.

Indemnity Benefits

Compensation paid to an injured worker (or relative) due to their loss of wages because of a work-related injury or illness.

Independent Medical Examination (IME)

When an employer or insurance carrier challenges a worker's claim, they may request the worker be examined by a medical professional other than the worker's own treating provider.

Indexed Claim (Auto-assembled via Claims Electronic Data Interchange [EDI])

A complete case without any of the following present: acceptance, denial, or report of payment.

Indexed Claim (Manually Assembled)

A complete case without any of the following present: acceptance, denial, or report of payment.

Insurance Agent

Representative authorized to bind policies for specific insurance carriers.

Insurance Broker

Person who arranges the purchase of insurance policies on behalf of the insured. Insurance brokers are not authorized to issue certificates of insurance.

Insurance Carrier

An insurance company that issues policies (for workers' compensation, disability benefits, and Paid Family Leave insurance).

Insurer

An entity that provides insurance coverage. This includes all insurance carriers that have issued policies and self-insured employers.

Insurer ID

The Workers' Compensation Board-assigned number (often referred to as a W Number or B Number) used to identify insurance carriers and self-insured employers. Formerly called the Carrier Code Number, the name was changed to Insurer ID to align with industry standards for Board-assigned W Numbers.

Insurance Policy

The insurance coverage contract between the employer and the insurance carrier.

Insurer FEIN

The Federal Employer Identification Number (FEIN) of the insurance company, self-insured employer, or guarantee fund that assumes the employer's financial responsibility for a claim.

DN0006 (Insurer Fein) is reported on FROI/SROI transactions and decoded to the W number as listed in the Claims Information System (CIS) Master ID file.

International Association of Industrial Accident Boards and Commissions (IAIABC)

An association of workers' compensation jurisdictional agencies from around the world, as well as private organizations involved in the delivery of workers' compensation benefits and services. The Board has adopted their electronic Proof of Coverage data standard and Electronic Data Interchange (EDI) Claims data standard for filing First and Subsequent Reports of Injury.

J

Job Protection

The right of an employee to return to their original job or a comparable position after being out on Paid Family Leave.

Job Tenure

The length of time (years, months, etc.) that a worker has held a particular job with a particular employer.

Judgment

Court order obligating a debtor to pay. The Board obtains judgments against employers that fail to pay monies owed on 525 penalties or 26a claims.

Jurisdiction

The right to hear and determine a workers' compensation case. The Board has jurisdiction over cases with employment in New York State (hired in, work in, control out-of-state employees from, claimant resident in, claimant domicile in, or injury occurrence in New York State) for persons in employment covered under the Workers' Compensation Law, Volunteer Ambulance Workers Benefit Law or Volunteer Firefighters Benefit Law. Notable exclusions from the Board's jurisdiction in New York State include federal government employees, certain employees of local governments, many NYC government occupations (civil service police, firefighters, sanitation workers), most NYC teachers, workers covered by separate compensation systems (maritime employments, merchant seafarers, interstate railroad employees, etc.), casual employments (yard work by minors, babysitters, etc.), etc. Coverage for some worker classes in New York is elective (e.g., sole proprietors, corporate officers, certain musicians, etc.).

Jurisdiction Claim Number (JCN)

The JCN is the WCB case number.

Related eClaims Data Element(s) (DN):

DN0005 (Jurisdiction Claim Number)

L

Labor Market Attachment

The legal obligation on the part of a workers' compensation claimant to show that they are making reasonable efforts to obtain gainful employment that is consistent with their medical restrictions. A partially disabled claimant need only seek employment within their medical restrictions. A claimant who fails to make reasonable efforts to obtain gainful employment consistent within their partial disability may be found to have voluntarily withdrawn from the labor market.

Legacy Claim

Any claim (with a case number) that existed in the Board's claim system prior to 5/23/14, which is when claim administrators began transmitting data electronically.

Level 1 Review (OnBoard)

The first level of review in the OnBoard prior authorization request (PAR) review process, used by the payer to review the initial PAR submission. The payer’s workload administrator assigns users as Level 1 reviewers to review the initial PAR submission.

Level 1 reviews are performed by the payer or can be delegated to a medical review organization (MRO), or to a pharmacy benefits manager (PBM) for Medication PARs. There is a Level 1 reviewer role for each PAR type.

Level 2 Review (OnBoard)

The second level of review in the OnBoard prior authorization request (PAR) review process, used by the payer to review PARs that have been granted in part or denied at the Level 1 review. The payer’s workload administrator assigns users as Level 2 reviewers. A treatment/testing PAR that has been granted in part or denied for medical reasons at the Level 1 review is automatically escalated to Level 2 review. Level 1 denial responses to Medication PARs are sent to the health care provider. The provider has the option to request a Level 2 review.

Level 2 reviews are performed by the payer's physician. They can also be delegated to a medical review organization (MRO). There is a Level 2 reviewer role for each PAR type.

Level 3 Review (OnBoard)

The third level of review in the OnBoard prior authorization request (PAR) process, used to escalate a PAR that has been granted in part or denied at the Level 2 review.

Level 3 reviews are initiated by the health care provider. Treatment/testing PARs that are granted in part or denied for medical reasons at the Level 2 review will not be automatically escalated for Level 3 review by the Board. The escalation to Level 3 review and subsequent resolution depends on the PAR type:

MTG PARs can be escalated by the health care provider in OnBoard and the Medical Director’s Office (MDO) will issue a Notice of Resolution.
Non-MTG Under or = $1,000 PARs can be escalated by the health care provider in OnBoard, but will be resolved through the adjudication process.
Disagreement over the claim administrator’s decision on Non-MTG Over $1,000 PARs are resolved through the adjudication process.

Licensed Representative

(a) Any person other than an attorney who is authorized by the Workers' Compensation Board to represent claimants before the Board and, in some instances, to receive a fee, fixed by the Board, for such services; also (b) any person other than an attorney who is authorized by the Workers' Compensation Board to represent self-insured employers before the Board.

Loss of Wage-Earning Capacity

A determination made by the Board as to the extent that a permanent partial injury or disability affects an injured worker's ability to earn wages.

Lost Time

A period of total wage loss and loss of earning capacity, beyond the waiting period (first seven days of disability for workers' compensation cases), caused by the claimant's work-related disability. In workers' compensation cases only, if the disability period exceeds 14 days, compensation will be paid from the first day of disability; there is no waiting period for volunteer ambulance worker or volunteer firefighter cases.

Lump-Sum Settlement

A negotiated and Board-approved agreement, termed a "non-schedule adjustment," between a claimant with a non-schedule permanent partial disability and the claim defendant(s). As a result of the agreement, the claimant receives a sum of money representing all future compensation for their disability, and the case is considered closed. Under Section 15(5-b) of the Workers' Compensation Law, granting of a settlement by the Board requires that (a) the right to compensation has been established and compensation has been paid for at least three months; (b) the continuance of disability and of future earning capacity cannot be ascertained with reasonable certainty; (c) there has been a physical examination of the claimant prior to approval; and (d) the Board considers the settlement "fair and in the best interest of the claimant." In practice, lump-sum settlements usually are final, but the Section provides for reopenings if the Board finds that there has been a change in condition or degree of disability not contemplated at the time of the settlement.

M

Maintenance Type Code (MTC)

A two-character code that identifies the claim event that requires the filing of a First Report of Injury (FROI) or Subsequent Report of Injury (SROI). In text that refers to FROI and SROI transactions, MTC immediately follows “FROI” or "SROI."

Related eClaims Data Element(s) (DN):

DN0002 (MTC)

Maintenance Type Code Filing Instructions

The Maintenance Type Code Filing Instructions detail the Maintenance Type Code that must be filed to report a specific claim event and the filing due dates for the claim event.

Managed Care

A system of health care delivery that tries to manage the cost of health care, the quality of that care and access to that care. Typical characteristics of managed care include a defined network of providers, a fixed reimbursement system, and a utilization review process (emphasizing both quality assurance and avoidance of unnecessary services). The Board instituted a managed care program for workers' compensation (including only voluntarily participating employers who meet qualifications criteria) in 1996, called Preferred Provider Organization (PPOs), authorizing insurance carriers and self-insured employers to contract with PPOs certified by the NYS Department of Health to provide services to diagnose, treat and rehabilitate injured workers requiring medical treatment.

Related eClaims Data Element(s) (DN):

DN0207 (Managed Care Organization Code)
DN0208 (Managed Care Organization Identification Number)

Managed Care Organization Code

An eClaims data element that provides information about the managed care organization. The following list gives the organization codes for managed care organizations and the required format:

The claim is not administered by an approved/certified Managed Care Organization = 00
The claim's medical losses are administered by a Preferred Provider Organization = 03

Related eClaims Data Element(s) (DN):

DN0207 (Managed Care Organization Code)

Managed Care Organization Identification Number

The number that identifies the managed care organization in a claim.

The following are the identification numbers for managed care organizations and the required format:

Key Insurance Business Works = 000000002
Metra Comp = 000000003
Brighton CS Network LLC d/b/a Magna Care = 000000004
United Health Services Hospitals = 000000015
Corvel = 000000018

Related eClaims Data Element(s) (DN):

DN0208 (Managed Care Organization Number)

Manual Classification Code

An eClaims data element that indicates the employee's primary occupation at the time of the injury or exposure to illness. The codes are loaded in October every other year from the NYCIRB (New York Compensation Insurance Rating Board) site.

Related eClaims Data Element(s) (DN):

DN0059 (Manual Classification Code)

Maximum Medical Improvement (MMI)

An assessed condition of a claimant based on medical judgment that (a) the claimant has recovered from the work-related injury to the greatest extent that is expected, and (b) no further change in condition is expected. A finding of maximum medical improvement is a normal precondition for determining the permanent disability level of a claimant.

Medical Care Benefits

Medical care provided in the case of a work-related injury or illness. These benefits, which include medical treatment, prescriptions, and equipment, may be accessed even when no claim has been made for weekly cash benefits and when there has been no time lost from work. They are a lifetime benefit. For eClaims, these codes are listed on the R3.1 Edit Matrix Valid Value Detail Page 1 in the Edit Matrix Table.

Related eClaims Data Element(s) (DN):

DN0216 (Other Benefit Type Codes)

Medical Fee Schedule

A schedule, established by the Chair of the Workers' Compensation Board, of charges and fees for medical treatment and care furnished to workers' compensation claimants.

Medical Review Organization (MRO)

An organization that provides independent medical review of the medical care an injured worker receives on a payer's behalf. Medical review organizations can be assigned as Level 1 or Level 2 reviewers for prior authorization requests (PARs) after they have completed an online registration and been designated as the Level 1 or 2 review organization by the payer.

Medical Treatment

Care (other than first aid) administered by a Board-authorized health care provider for the treatment of a work-related injury or illness.

Medical Treatment Guidelines (MTGs)

A suite of guidelines developed by the Board that sets forth the recommended medical care in the treatment of work-related injuries or conditions. The Workers' Compensation Board's New York Medical Treatment Guidelines (MTGs) are the standard of care for treating injured workers in the New York State system and are based on the best available medical evidence and the consensus of experienced medical professionals.

Medication PAR

A type of OnBoard prior authorization request (PAR) used for medication requests (replacing the current New York Workers' Compensation Formulary [Formulary] prior authorization request process). With the implementation of OnBoard: Limited Release Phase One, medical marijuana will also be requested via a Medication PAR, which will replace the current process using the Attending Doctor's Request for Approval of Variance and Carrier's Response (Form MG-2).

Memorandum of Decision

A decision issued to the parties in a claim to document the findings of a panel of three Board members who review the case after a party has appealed a decision issued by a Workers' Compensation Law judge.

Military Family Support

A qualifying event for Paid Family Leave in which the employee takes paid leave to assist with family matters that arise when a spouse, domestic partner, child, or parent of the employee is on active military duty or has been notified of an impending call or order of active duty to a foreign country.

Modify (a Decision)

A decision that partially changes a previous decision, e.g., a Board Panel memorandum of decision (MOD) that amends a Workers' Compensation Law Judge's decision.

MTG Confirmation PAR

A type of prior authorization request (PAR) used to request confirmation from the insurer that the procedure or test is based on a correct application of the Board's New York Medical Treatment Guidelines, which was previously done using the Attending Doctor's Request for Optional Prior Approval and Carrier's/Employer's Response (Form MG-1). Note: Under the Form MG-1 process, the form was optional for health care providers, and it was optional for payers to respond. In OnBoard: Limited Release, this PAR type remains optional for health care providers, but payers are required to respond.

MTG Special Services PAR

A type of OnBoard prior authorization request (PAR) used to request authorization for special service(s) not included on the list of pre-authorized procedures, which was previously done using the Attending Doctor's Request for Authorization and Carrier's Response (Form C-4AUTH). Note: This process will mirror the MTG Variance PAR process, rather than the Non-MTG Over $1,000 PAR process.

MTG Variance PAR

A type of OnBoard prior authorization request (PAR) used to request testing or treatment that varies from the Board's New York Medical Treatment Guidelines applicable to the body part or condition being treated, which was previously done using the Attending Doctor's Request for Approval of Variance and Carrier's Response (Form MG-2).

N

Nature of Injury/Illness

A numeric coding structure (two digits, 54 codes) used as part of eClaims, and required by the International Association of Industrial Accident Boards and Commissions for Electronic Data Interchange transactions, to identify the nature of injury on First Report of Injury transactions (e.g., 10=Contusion; 28=Fracture). See WCIO codes.

Related eClaims Data Element(s) (DN):

DN0035 (Nature of Injury Code)

New York State Assessments

A separate identifiable policy charge, paid by employers, established by the New York Legislature as of 4/1/94, to provide primarily for the funding of Special Funds and Board expenses.

New York State Average Weekly Wage (NYSAWW)

The average weekly wage paid in New York State during the previous calendar year as reported by the Commissioner of Labor to the Superintendent of Financial Services on March 31 of each year.

New York State Insurance Fund (NYSIF)

New York State agency whose activities include (a) providing workers' compensation insurance coverage to private and public employers, (b) providing other lines of insurance coverage (disability benefits, etc.) and (c) acting as an agent for New York State in workers' compensation cases involving NYS employees. NYSIF assures safe workplaces for employees, by guaranteeing that workers' compensation insurance will be made available to employers who cannot secure coverage elsewhere.

No Further Action (NFA)

A case status that removes a case from further consideration on the calendar unless action is taken by parties of interest. The decision to change the status of a case to No Further Action (NFA) is based upon the determination that no further rulings by the Board can be made unless action is taken by the parties of interest. This case status is indicated by a statement on a Board decision (e.g., “No further action is planned by the Board at this time”).

Non-compliance

Failure of an employer to obtain workers' compensation, disability benefits or Paid Family Leave insurance coverage when required to do so by law.

Non-MTG Over $1,000

A type of OnBoard prior authorization request (PAR) used for requests for treatment costing over $1,000 for non-MTG body parts, which was previously done using the Attending Doctor's Request for Authorization and Carrier's Response (Form C-4AUTH).

Non-MTG Under or Equal to $1,000

A type of OnBoard prior authorization request (PAR) used for requests for treatment costing $1,000 or less for non-MTG body parts. This PAR type is optional for the health care provider, but a response from the payer is mandatory.

Non-Schedule Permanent Partial Disability

Non-fatal injuries resulting in a permanent disability involving a part of the body or a condition that is not covered by a Schedule Loss of Use award and is based on the employee's permanent loss of wage-earning capacity and the date of the work-related accident or disablement.

Notice

Written notification from an employee to their employer, indicating that a work-related injury or illness has occurred. For injuries, notice must be given no later than 30 days after the accident. The Board may excuse a failure to give notice on the grounds that (a) for some reason, notice could not have been given; (b) the employer had knowledge of the accident; or (c) the employer's case has not been prejudiced. In cases involving occupational diseases, the time period for notice is two years from the date of disablement or from the date when the employee knew, or should have known, that the disease was due to the nature of employment.

Notice of Decision

A decision issued to the parties in a claim to document findings and awards made by a Workers' Compensation Law judge at a hearing.

Notice of Interpreter Services

A document that lets injured workers and other public stakeholders know that interpreter services are available to them. The information on this document is translated into 13 languages. The Notice is included when documents are mailed to a claimant, such as a decision generated by the Claims Information System (CIS) or a Notice of Resolution, or when an Order of the Chair is generated by OnBoard.

Notice of Resolution

A determination by the Medical Director's Office (MDO) regarding a request for review of a Level 2 denial or grant in part of a prior authorization request (PAR). The PAR types reviewed by the MDO are for tests and treatment related to the New York Medical Treatment Guidelines, medication, or durable medical equipment only. The MDO reviews these requests and makes its determination based on medical necessity.

The MDO also issues a Notice of Resolution when there is no insurer response to:

Special Services PARs (all categories)
Medication PARs in the following therapeutic categories: narcotic, anti-anxiety agent, skeletal muscle relaxant, and medical marijuana
Confirmation and Variance PARs that are not eligible for an automatic Order of the Chair, without a medical necessity determination

Notice of Stipulated Decision

A decision, approved by the Board, issued to the parties in a claim to memorialize findings and awards the parties have agreed to in writing.

Notifications

Update messages viewable within OnBoard: Limited Release (e.g., work queue notifications) or via email (email notifications apply to external users only) that announce something new for the user to see. Notifications are used to indicate items such as the successful completion of a task, an error, warning message, or that new information has been added to the system (e.g., claimant attorneys receiving notifications when a new document is placed in eCase, which is new with OnBoard: Limited Release).

O

Occupational Disease (OD)

A disease arising from employment conditions for a class of workers, with the disease occurring as a natural incident for particular occupations, distinct from and exceeding the ordinary hazards and risks of employment. To be considered an occupational disease, there must be some recognizable link between the disease and some distinctive feature of the worker's job.

In eClaims, DN0290 is used to indicate an occupational disease. The following codes are used:

02 = Occupational Disease – An injury caused by exposure to a disease-producing agent in the workers' occupational environment. Injuries of this type are not traceable to a definite accident during the worker's past or present employment.
03 = Cumulative Injury (Other than Disease) – An injury having occurred from, or aggravated by, a repetitive employment activity. Injuries of this type are not traceable to a definite accident during the worker's past or present employment.

Related eClaims Data Element(s) (DN):

DN0290 (Type of Loss Code)

Occupational Disease, Notice and Causal Relationship (ODNCR)

Minimal conditions that must be met before financial responsibility can be assigned to a claim for workers' compensation based on occupational disease. Specifically, it must be established that (a) the claimant has an occupational disease recognized by the Workers' Compensation Law; (b) the claimant has, after the onset of the disease, notified their employer within the time limit set by the Workers' Compensation Law for occupational diseases (two years from date of disablement or from date when claimant knew or should have known that the disease was due to the nature of the employment, whichever is greater); and (c) a causal relationship exists between work-related activities and exposure, the development of the occupational disease, and a subsequent disability.

OnBoard

The online business information system being developed by the New York State Workers' Compensation Board.

OnBoard will eventually replace the Board's existing computer claims systems with a single, web-based platform, providing stakeholders with increased accuracy, paperless transactions, and a user-friendly interface for interacting with the Board.

OnBoard: Limited Release

The first phase of OnBoard, designed to move several key processes for health care providers and insurers from paper to online. This includes the prior authorization (PAR) process for medication, durable medical equipment and medical treatment or testing. It also includes the submission of Request for Decision on Unpaid Medical Bill(s) (Form HP-1.0 in OnBoard: Limited Release).

Onset Date

The starting date of disablement for an occupational disease, as established by the Board.

Order of the Chair (OOC)

A directive by the Chair, either via Form EC-325, or automatically via OnBoard: Limited Release, that approves a prior authorization request for treatment when the insurer does not respond to the request within the specified time frame. This includes treatment that varies from the Board's New York Medical Treatment Guidelines and non-MTG related treatment requests.

Other Benefit Type Codes

An eClaims data element indicating additional benefit types paid by the insurer. Other benefit types can include funeral expenses, penalties, hospital costs, payments to physicians, medical travel expenses, etc. The codes are listed on the R3.1 Edit Matrix Valid Values Detail Page 1 Table in the Edit Matrix Table.

Related eClaims Data Element(s) (DN):

DN0216 (Other Benefit Type Codes)

P

Paid Family Leave

Job-protected, paid time off to bond with a newly born, adopted, or fostered child, care for a family member with a serious health condition, or assist loved ones when a spouse, domestic partner, child, or parent is called to active military service. Paid Family Leave may also be available in some situations when an employee or their minor, dependent child is under an order of quarantine or isolation due to COVID-19.

Paid Family Leave Benefits

Time off and wage replacement benefits for employees who have a qualifying event for Paid Family Leave.

Paid Family Leave Insurance Coverage

The insurance that most private employers must carry to provide Paid Family Leave benefits to their employees, typically as a rider to an employer's disability insurance policy.

Paid Family Leave Request

A request to take job-protected, paid time off to bond with a newly born, adopted, or fostered child, care for a family member with a serious health condition, assist loved ones when a spouse, domestic partner, child, or parent is called to active military service, or in some situations when an employee or their minor, dependent child is under an order of quarantine or isolation due to COVID-19.

Part of Body Injured

A numeric coding structure consisting of 56 two-digit codes (two digits, 56 codes) used as part of eClaims, and required by the International Association of Industrial Accident Boards and Commissions for Electronic Data Interchange transactions, to identify the nature of injury on First Report of Injury transactions (e.g., 32=Elbow; 42=Lower Back Area).

Related eClaims Data Element(s) (DN):

DN0036 (Part of Body Injured Code)
DN0422 (Part of Body Injured Fingers/Toes Location Code)
DN0421 (Part of Body Injured Location Code)

Partial Denial (PD)

A Subsequent Report of Injury (SROI) Maintenance Type Code used when a claim administrator is denying indemnity in part or whole on a claim. A SROI-PD transaction cannot be used to deny medical on the claim.

Party of Interest (POI)

Any person or organization (e.g., the insurer, claimant representative, hospital, etc.) that is placed on notice for hearings and/or decisions.

Payer

An entity that makes payments in a workers' compensation claim. A payer can be an insurance carrier, third-party administrator (TPA), or self-insured employer.

Payroll Deduction

Amount taken from an employee's paycheck to fund the cost of Paid Family Leave coverage. The deduction rate is set each year by the NYS Department of Financial Services to match the cost of coverage.

Penalties

Assessments against insurers, employers and claimant attorneys/licensed representatives for specific violations covered in Section 25 of the Workers' Compensation Law or Section 330.2 of Title 12 of the New York Code Rules and Regulations (NYCRR).

Permanent Partial Disability (PPD)

A worker's wage-earning capacity is partially lost forever. There are two types of permanent partial disability benefits, depending on the body part affected and the nature of the permanent disability: schedule loss of use and non-schedule.

Permanent Total Disability (PTD)

A worker's wage-earning capacity is lost forever. In some cases, the worker may continue to earn income if their wages and weekly benefits don't exceed the maximum amounts set by law. There is no limit on the number of weeks this benefit may be paid.

Physical Rehabilitation

A medical treatment or therapy program (e.g., exercise programs, training in the care and use of a prosthetic device) designed to help an individual cope with or overcome the physical effects (e.g., motor deterioration) of a physical disability.

Premium

The total amount paid for an insurance policy. For workers' compensation insurance, premiums are normally calculated using a rate per $100 of the payroll for covered employees.

Prior Authorization Request (PAR)

A request from the injured worker's health care provider to the insurer for prior approval of certain treatments, medications, or durable medical equipment (DME) to ensure that the costs associated with the treatment, medication, or DME are covered under workers' compensation. A PAR must be submitted when a request for treatment falls outside the Board's New York Medical Treatment Guidelines. Disputes related to the medical necessity of the treatment may be resolved by the Medical Director's Office or Adjudication depending on the PAR type. In OnBoard: Limited Release, each PAR type has its own form ID. See DME PAR, Medication PAR, MTG Confirmation PAR, MTG Special Services PAR, MTG Variance PAR, Non-MTG Over $1,000 PAR, and Non-MTG Under or Equal to $1,000.

The three typical PAR review levels still apply. Claim administrators manage the first two levels: Level 1 can be handled by anyone, while Level 2 must be executed by a physician. A Level 3 review is undertaken by the Board.

Note: Level 3 reviews apply only to Medication, MTG, and DME PARs. Non-MTG PARs after Level 2 can be disputed through Adjudication but these are not considered a Level 3 review.

Private Employer

An employer/business that is controlled by an individual person or commercial company, rather than by the state or an official organization.

Private Sector

The part of the economy that is owned, managed, and controlled by individuals and organizations as a means of enterprise and profit.

Proof of Coverage (POC)

Electronic transactions submitted to the Board that report all policy and coverage activities for insured employers. Transactions include issuing, canceling, reinstating, and renewing coverage under a specific policy.

Proposed Decision

A decision with findings and awards, proposed by a conciliator, that is issued to the parties in a claim.

Pro-Se Claimant

A pro-se claimant is an individual who is not represented by an attorney or licensed representative.

Protracted Healing Period (PHP)

In cases involving a schedule permanent partial disability, if the Board finds that the healing period (period of temporary total disability) exceeds the normal healing period allowed for the injury by the Workers' Compensation Law (Section 15(4-a)) then awards for the protracted healing period may be added to the award. (e.g., A claimant suffers a 25% permanent loss of use of an arm (.25 x 312 week maximum = 78 weeks schedule award) and the claimant is judged to have been unable to work for 40 weeks, rather than the 32-week normal healing period; the award is for 78 (schedule) + 8 (protracted healing) = 86 weeks).

Provider

A health care provider who treats injured workers. Providers may also take part in certifying Paid Family Leave for bonding or family care and entitlement to disability benefits. Physicians, chiropractors, licensed clinical social workers, nurse practitioners, acupuncturists, physician assistants, occupational therapists, and physical therapists are eligible for Board authorization and must be authorized by the Board in order to treat injured workers. Providers such as dentists and radiologists are not eligible for Board authorization, however, may treat injured workers.

Public Employer

The state, political subdivisions of the state, municipal corporations, public authorities, or any other government agency.

Public Sector

The part of the economy that provides a range of governmental services, including infrastructure, public transportation, education, health care, police, and military service.

Q

Qualifying Military Event: Qualifying exigency as interpreted under the military provisions of the federal Family and Medical Leave Act, arising out of the fact that the spouse, domestic partner, child, or parent of the employee is on active duty or has been notified of an impending call or order to active duty.
Quick Code Reference List: See Valid Value Detail Page 1 and Valid Value Detail Page 2

R

R Form

A form that the insurer is required to file with the Chair after the earliest of (a) the date on which the claimant's total lost time exceeds eight weeks; (b) the date on which rehabilitation services were instituted or arranged; or (c) the date on which rehabilitation services were deemed necessary, even if not instituted or arranged. The form includes information about the case, date of disablement, lost time, injury diagnosis, claimant's occupation, attending physician and information about current medical/vocational rehabilitation services, if any. The R forms are reviewed by Integrated Services (formerly the Rehabilitation Bureau) to determine whether follow-ups (e.g., with the claimant) are appropriate.

R Number

A Workers' Compensation Board-assigned number used to identify attorneys, attorney firms or licensed representatives representing injured workers, employers, carriers, third-party administrators, and a Special Funds Conservation Committee. Any attorney, attorney firm, or licensed representative is eligible to request an R Number from the Board.

Receiver

A person appointed by the court to hold in trust and administer property under litigation, to wind up the affairs of a business, or to manage a corporation during its reorganization.

Redetermination

An administrative review requested by entities that have had penalties assessed for non-compliance with Workers' Compensation Law.

Reduced Earnings

A compensation rate based on the claimant's partial wage loss or partial loss of earning capacity due to a condition related to a compensable work-related injury.

Rehabilitation Services

Services aimed at restoring an individual to an adequate or to an optimal state of health, constructive activity, or employment (see also Physical Rehabilitation, Vocational Rehabilitation).

Reimbursement, Request for

(a) A request by an employer for reimbursement for wages paid to an employee for a period during which the employee was eligible to receive workers' compensation or disability benefits; (b) a request by a workers' compensation carrier for reimbursement out of the Special Disability Fund (Second Injury Fund); (c) a request by a disability benefits carrier for reimbursement of benefits paid to a claimant while the workers' compensation case was being litigated.

Reinstatement

Action to restart or resume a previously terminated policy.

Rejected Transaction

A First or Subsequent Report of Injury transaction that does not meet all Data Element requirements and Edit Matrix Table requirements for the specific transaction. Only transactions that are accepted by the Board are considered received by the Board for claims purposes. A rejected transaction that is not resubmitted successfully to the Board could result in a penalty, if applicable.

Remittance Advice Remark Codes (RARC)

Codes used by payers to provide additional explanation for an adjustment already described by a Claim Adjustment Reason code (CARC) or to convey information about remittance processing.

Reopened Case

A workers' compensation case that has been closed by a Workers' Compensation Law Judge or a Board Panel that is subsequently made active again to determine the claimant's eligibility for benefits.

Report of Payment

A term used by the Board to describe any SROI transaction that reports a payment on a claim.

Request for Further Action (RFA)

A Board form filed by the insurer, self-insured employer, or claimant and/or the claimant's attorney asking the Board to take a specific action, including reopening a case, or alerting the Board to any problem or situation affecting the claim in question.

Please note: Medical providers also use the “RFA” abbreviation when describing a Request for Authorization. The definition above applies only to a Request for Further Action.

Reserved Decision

A decision issued to the parties in a claim to document findings and awards made by a Workers' Compensation Law judge (WCLJ) after review of relevant evidence submitted after record development.

Rescind (a Decision)

A Board Panel memorandum of decision (MOD) that voids or annuls a Workers' Compensation Law Judge decision. (Decisions to rescind are usually issued without prejudice in order to allow the parties to present evidence or testimony not previously presented to a Workers' Compensation Law Judge.)

Review, Request for

A written request for a Board Panel review of a Workers' Compensation Law Judge decision.

Reviewer (OnBoard)

A prior authorization request (PAR) review process role in OnBoard. Reviewers can be assigned to Level 1 and Level 2 review. Reviewers review PARs as assigned.

S

Scanned Document

A document that was received from an outside party in an approved format (i.e., paper mail, fax, email, secure upload or Secure File Transfer Protocol [SFTP]) that is converted to an image file by the scanning vendor or through an eForm connected to a Board system. Papers received together may be sorted, kept together, or separated based on desk list rules defined by the Board and followed by the vendor but all pages within a single document would have been received together.

Schedule Loss of Use Award (SLU)

A cash benefit that pays the claimant for the loss of wage-earning capacity (as determined by the Board, with proper consideration of the Workers' Compensation Law and current Permanent Impairment Guidelines) resulting from a permanent functional impairment of a body part as a result of the claimant's on-the-job injury. An SLU award is made when an employee has permanently lost the use of an extremity, eyesight, or hearing. This type of award is issued by the judge who determines the amount of loss. The award is limited to a certain number of weeks based on the severity and type of loss, and any temporary benefits that have been paid are deducted from the SLU award.

Search/Search Fields

Feature that enables users to find information in OnBoard: Limited Release. Users submit a keyword or phrase (query) to search the index and receive the most relevant results. The “Jump To” feature leverages a drop-down menu to search a specific term (such as System ID or Insurer), returning a narrower, more targeted set of responses.

Second Injury Fund (Also Disability Fund)

A special fund, technically known in New York as the Special Disability Fund, which is now closed. The fund assumed, in certain cases, part of the permanent disability liability resulting from injuries to workers with preexisting disabilities. It was funded by assessments against insurers and self-insured employers, and was created to ensure that workers with disabilities receive full workers' compensation benefits, while encouraging employers to hire people with disabilities by protecting them against disproportionate liability in the event of subsequent employment injury.

Section 32 Waiver Agreement/Settlement

A negotiated agreement between the injured worker and the insurer to settle indemnity and/or medical benefits on a claim. A waiver agreement ends the right of an injured worker to ongoing and future benefits in exchange for a lump-sum payment or an annuity. If agreed upon and approved by the Board, whatever is settled (indemnity and/or medical benefits) is closed forever. The insurance carrier will no longer be responsible for that part of the claim, and it cannot be reopened. If indemnity benefits are settled, no further payments for lost wages will be made. If medical benefits are settled, the insurance carrier will no longer pay for medical care. A waiver agreement is not binding unless it is approved by the Workers' Compensation Board.

Self-Insurance

A method by which an employer or group of employers may secure the payment of workers' compensation benefits to employees by depositing securities or a surety bond in an amount required by the Board (this requirement is waived for local government self-insureds); the self-insurance method is in lieu of purchasing insurance from an insurance carrier.

Self-Insured Employer

An employer that is authorized by the Board to cover the cost of workers' compensation benefits (lost wage replacement and medical treatment), as well as disability benefits, and Paid Family Leave for their employees.

Sequela (pl. Sequelae)

A disease or other medical condition following from, and usually related to, a previous disease or condition; in workers' compensation cases, the possibility of sequela can result in accidental injuries that are different from resulting work disabilities, e.g., an accident results in an injured knee, and efforts to hobble back to work with the injury result in a back strain.

Serious Health Condition

An illness, injury, impairment, or physical or mental condition that involves in-patient care in a hospital, hospice, or residential health care facility, or requires continuing treatment or supervision by a health care provider. Employees may take Paid Family Leave to care for a family member with a serious health condition.

Servable Document

A printable copy of the First Report of Injury (FROI) or Subsequent Report of Injury (SROI) transaction found in the case folder that can be sent by parties whenever a copy of the document must be filed with the claimant, the claimant's attorney, a health care provider, etc. Any registered eCase user who is a party of interest on the case has access to these documents in eCase.

Social Security Number (SSN)

The nine-digit identification number assigned by the Social Security Administration for individuals.

Related eClaims Data Element(s) (DN):

DN0042 (Employee Social Security number)

Special Disability Fund

See Second Injury Fund

Special Funds Group (SFG)

An entity created within the Board's Division of Financial Administration responsible for defending the Special Disability Fund and administering the reimbursement of indemnity and medical benefits payable from the special funds. The Special Funds Group was created in 2017 to replace the Special Funds Conservation Committee.

Standard Earned Premium

See Premium

Status Quo Ante

Latin phrase meaning “that which existed before,” used to signify that a claimant's health has returned to what it was before the occurrence of the accident.

Stay

To stop or delay action on something pending an appeal or review. Under Workers' Compensation Law Section 23, when a party files an application for review from a Workers' Compensation Law Judge's (WCLJ) decision, the portion of the award that is under appeal is stayed. For example, if a payer appeals the WCLJ finding of total disability, but its consultant says moderate disability, then during the appeal, the payer must pay the conceded moderate rate, but need not pay at the total rate. Even if the payer loses the appeal, it should not be penalized for late payment under Section 25(3)(f).

Subrogation

The assignment of a cause of action against a third-party by the claimant to the insurer. If cause for an action (e.g., a product liability lawsuit) against a third-party exists based on a work injury or illness, and the claimant fails to commence such action within the period specified by Section 29 of the Workers' Compensation Law (six months after the awarding of compensation or nine months after the enactment of new laws permitting additional remedies), the failure operates as an assignment of the cause of action to the insurer liable for the payment of compensation benefits.

Subsequent Report of Injury (SROI)

A record of an event sent to the Board that completes a subsequent report of injury requirement.

Sweep Benefit

A previously paid benefit that is reported on a Subsequent Report of Injury (SROI) transaction but is not the Benefit Type specifically associated with the current SROI transaction. Only a limited amount of benefit information is required to be submitted by the claim administrator for a Sweep Benefit.

Symptomatic Treatment

Medical treatments aimed at providing relief from the symptoms of a disease or injury, rather than providing a permanent remedy to the underlying condition.

System ID

A unique identifier for items housed in OnBoard: Limited Release. These run from the claimant's identification to simple electronic submissions.

T

Temporary Partial Disability (TPD): An injury/illness in which the worker temporarily loses part of their wage-earning capacity. Lost wage benefits may be paid for periods of partial wage loss during the workers' recovery period following an accident or exposure.
Temporary Total Disability (TTD): An injury/illness in which the worker temporarily loses all of their wage-earning capacity. Lost wage benefits may be paid for periods of total wage loss during the worker's recovery period following an accident or exposure.
Tentative Rate: A weekly rate assigned by the Board for indemnity payments, pending final adjudication of outstanding issues relating to benefit rates.
Third-Party Action: Lawsuits against equipment manufacturers, facility owners and other non-employer parties whose products or services contributed to the occurrence of an accident. Under the Workers' Compensation Law, a compensation claim is a worker's sole remedy against the employer, but lawsuits may be initiated against third parties for contributory negligence, product defects, etc.
Third-Party Administrator (TPA): A person, firm, corporation, or insurer licensed by the Board to solicit the business of representing self-insured employers or insurance carriers in dealings with the Board.
Third-Party Settlement: An agreement to end a lawsuit in exchange for compensation or other benefit.
Trading Partner: An entity that enters into an agreement with the Board to exchange data electronically. A trading partner can be an insurance company, licensed third-party administrator, or self-insured employer.
Typist Form Letter (TFL): A user-generated letter or notice sent to the stakeholder related to a NYS workers' compensation system inquiry or issue.

U

Unemployment Insurance Employer Registration Number (UIER): A seven-digit identification number the NYS Department of Labor (DOL) issues to employers who are required to contribute to unemployment insurance.

V

Valid Value Detail Page 1 and Valid Value Detail Page 2: A reference list of the IAIABC codes that the Board will be accepting in eClaims Release 3.1. The list provides a summary of Maintenance Type Codes, Benefit Type Codes, Full Denial Reason Codes, and other commonly used codes in First Report of Injury (FROI) and Subsequent Report of Injury (SROI) transactions. The list is available in the Valid Values Detail 1 sheet of the Edit Matrix Table.
Virtual Hearings: Workers' compensation hearings that participants can attend remotely, using a computer or mobile device.
Vocational Rehabilitation: A structured process designed to improve the employment potential of a person whose earnings potential has been reduced by injury, disease, prolonged absence from the work force or other events. Vocational rehabilitation services may include counseling, vocational evaluations, assisted job search, trial placement in a job, on-the-job training, vocational or academic schooling, job modification, workplace redesign, transportation services, etc.
Volunteer Ambulance Workers Benefit Law (VAWBL): Chapter 64-b of the Consolidated Laws, the basic New York State law covering work-injury compensation benefits for volunteer ambulance workers.
Volunteer Firefighters Benefit Law (VFBL): Chapter 64-a of the Consolidated Laws, the basic New York State law covering work-injury compensation benefits for volunteer firefighters.

W

Wage

An eClaims data element reported on the First Report of Injury. It is the estimate of the Average Weekly Wage provided by the employer. These are the gross wages of the claimant. In the Claims Information System FROI/SROI tab, the Wage is shown under Wages/Salary on Latest Values as “estimated wage.”

X

XML Agreement: An agreement between the treating health care provider and the Board to submit the CMS-1500 form and medical narrative attachment electronically via Extensible Markup Language (XML). An XML agreement is required for all providers who wish to submit the CMS-1500 electronically to the Board. Each provider in a group practice must complete an XML agreement via the Board's Medical Portal.
XML Submission: The zip file submitted to the Board by the XML submission partner. The XML submission contains the discrete data described by the schema and all attachments.
XML Submission Partner: A company that submits CMS-1500 medical bills via extensible markup language (XML) on behalf of health care providers. An XML submission partner may also be referred to as a "clearinghouse."

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