Board Bulletins and Subject Numbers

May 4, 2018

I. REIMBURSEMENT PROCEDURE

OVERVIEW

Since October 1, 2016, the Special Funds Group (SFG) of the Workers’ Compensation Board has processed all reimbursement requests for Workers’ Compensation Law (WCL) §§ 14(6) and 15(8) claims (see Subject Number 046-919 Transition from Special Funds Conservation Committee to Special Funds Group on all §§ 14(6) and 15(8) Claims).

Effective June 1, 2018, the following forms, version date 5-18, must be used for reimbursement requests (prior versions will not be accepted):

• Carrier’s Notification of Initial Request for Reimbursement Under WCL Section 14(6) or Section 15(8) (Form C-251N)
• Carrier’s Request for Reimbursement of Indemnity Payments Under WCL Section 14(6) or Section 15(8) (Form C-251 Excel)
• Carrier’s Request for Reimbursement of Medical Payments Under WCL Section 15(8) (Form C-251.1)
• Carrier’s Request for Reconsideration of Reduction Under WCL Section 14(6) or Section 15(8) (Form C-251.6) (see below)
  
  Note: The Carrier’s Request for Reimbursement of Indemnity Payments Under WCL § 14(6) (Form C-251.2A) is now obsolete. All requests for indemnity reimbursement must be submitted on Form C-251.

The Waiver Agreement Management Office (WAMO) section of the Board’s website contains revised forms, new forms, and instructions on how to complete them. Please visit: WCL §§14(6) and 15(8) Reimbursement Requests.

SFG REVIEW OF REQUESTS FOR REIMBURSEMENT

Once a request for reimbursement (Form C-251 or Form C-251.1, as appropriate) is filed, insurance carriers will receive a confirmation of receipt, which may include information about certain requests that were not accepted by SFG because the item was not completed properly. The confirmation will be issued by SFG via email, and will include a reference number to be used for any follow-up or amendment to a submission.

All requests will undergo a review by SFG staff and, upon completion, a response (Form C-251R or Form C-251.1R) will be emailed to the insurance carrier with an explanation of any reductions. Reimbursement shall only be available for compensation payments and medical expenses that are provided for under the Workers’ Compensation Law. Thus, it remains the responsibility of the insurance carrier to administer its claims accordingly.

Note: All amounts requested that were approved at this stage will be submitted for payment processing. Insurance carriers should allow fourteen (14) days from receipt of the response for payment to be issued.

All reimbursement requests are subject to audit by the Office of the State Comptroller (OSC) prior to payment. In the event OSC requires a reduction, SFG will email the carrier an amended response with an explanation of any such additional reductions.

RECONSIDERATION OF THE SFG RESPONSE

After the insurance carrier receives the SFG response (Form C-251R or C-251.1R), it is the responsibility of the insurance carrier to review it and identify any reductions to its reimbursement request.

An insurance carrier who disputes a reduction may submit a request for reconsideration by completing and emailing Form C-251.6 to SpecialFunds@wcb.ny.gov within sixty (60) calendar days of the date marked on Form C-251R or Form C-251.1R. Additional evidence not previously submitted that supports the request may be attached to Form C-251.6.

Senior SFG staff not integral to the original review will complete an independent review of the reimbursement request and any additional documentation submitted with Form C-251.6. Upon completion of the review, a response (Form C-251.6R) will be emailed to the insurance carrier and is deemed the final determination by SFG.

Note: Any payment resulting from this reconsideration is also subject to audit by the Office of the New York State Comptroller (OSC). Also note, reconsideration is only an available remedy when the amount requested has been reduced by review of a submission by SFG or OSC staff. Form C-251.6 may not be used for new requests not previously submitted on the applicable form.

ADMINISTRATIVE PROCESSING

If the insurance carrier disputes the reconsideration made by SFG, the insurance carrier may request desk review by a Workers’ Compensation Law Judge by filing a Request for Further Action by Carrier/Employer (Form RFA-2) within thirty (30) calendar days of the date marked on the Form C-251.6R. When seeking such review, the carrier must attach the SFG response (Form C-251.6R) to Form RFA-2. Pending modification to Form RFA-2, carriers must use the box marked “other” and indicate that the purpose of the request is “Desk review of SFG Decision Form C-251.6R.” Failure to include this statement and a copy of Form C-251.6R may result in delay or rejection of the request.

Note: Administrative Processing is only available as a remedy after a final determination, in which the amount requested has been reduced, has been made by the Senior SFG staff in response to a reconsideration request.

If you have any questions regarding reimbursement requests from SFG, please contact the Special Funds Group either by phone at (855) 430-3602, or by email at SpecialFunds@wcb.ny.gov.

II. ESTABLISHMENT

In accordance with the 2007 announcement of the closing of the Special Disability Fund, and pursuant to the Board’s authority under Section 15(8), effective June 1, 2018, in all cases where the insurance carrier believes it has sufficient evidence in support of a Section 15(8) finding, and where Section 15(8) has not yet been established in a decision issued by the Board, or where Section 15(8) has been established pending permanency or classification, the insurance carrier must adhere to the following procedure.

When the claim for Section 15(8) is believed to be ripe for consideration (generally immediately prior to a hearing at which the claimant will be classified or soon after a permanency determination has been made), and not before that point, the insurance carrier seeking establishment must submit a one-page document to the Special Funds Group at SFGmail@wcb.ny.gov which:

• Specifies, by Document Identification number, all documents present in the Board’s electronic case folder, dated as filed as of July 1, 2010, that support the insurance carrier’s request for Section 15(8) establishment;
• Includes a no more than one-sentence description as to what element of Section 15(8) each Document Identification number is asserted to satisfy (e.g., “M & S statement”); and
• References all evidence that the insurance carrier relies on in support of its claim for Section 15(8) applicability.
  • Note: There is no form for this submission. Submissions should be titled and referenced as “Request for 15(8) finding per Subject Number 046-1063.”

If a decision has already been issued by the Board establishing Section 15(8) pending permanency or classification, the insurance carrier need only identify the document or documents that support the evidentiary requirement of permanency as of July 1, 2010.

This one-page document must be submitted in any case where the insurance carrier wishes to formalize the establishment of 15(8) liability and begin submitting 15(8) reimbursement requests. This document is required even if a prior Pre-Trial Conference Statement was completed with the Special Funds Conservation Committee.

Note: The purpose of this announcement is to advise the parties of this new administrative procedure for establishing Section 15(8) liability. There is no deadline for submitting these one-page documents.

Once review of the Request for 15(8) finding per Subject Number 046-1063 has been completed, the SFG will either advise the Board of its voluntary acceptance of liability, or the SFG will request a hearing on behalf of the insurance carrier in order to address the request. The Board will not initially schedule a hearing upon receipt of the request of the insurance carrier to address Section 15(8) liability; rather, if the SFG does not voluntarily accept liability, it will request a hearing on behalf of the insurance carrier.

If you have any questions regarding WCL § 15(8) establishment, please contact the Special Funds Group either by phone at (855) 430-3602, or by email at SFGmail@wcb.ny.gov .