Health Insurers Request For Reimbursement {HIMP-1}

HIMP-1 - NEW YORK STATE WORKERS’ COMPENSATION BOARD HEALTH INSURANCE MATCHING PROGRAM. This is a New York State Workers’ Compensation Board form used by health insurers, health benefit plans, and authorized Health Insurance Matching Program (HIMP) agents to seek reimbursement for medical benefits paid on behalf of injured workers whose treatment may be covered under workers’ compensation. The form includes sections for submitting a reimbursement request, allowing a workers’ compensation carrier or employer to object to all or part of the claim, and requesting arbitration when reimbursement disputes cannot be resolved. It captures claim information, payment details, carrier responses, and arbitration requests, helping ensure compliance with New York Workers’ Compensation Law and applicable reimbursement procedures. www.FormsWorkflow.com