New York > Workers Compensation
Health Providers Request For Decision On Unpaid Medical Bills HP-1 - New York
| Health Providers Request For Decision On Unpaid Medical Bills Form. This is a New York form and can be used in Workers Compensation . |
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STATE OF NEW YORK - WORKERS COMPENSATION BOARD HP-1 (4-05) Office of Health Provider Administration (1-800-781-2362) HEALTH PROVIDERS REQUEST FOR DECISION ON UNPAID MEDICAL BILL(S) This original form may be completed and forwarded with required attachment s* to the Workers Compensation Board, Office of Health ProviderAdministration, 100 Broadway-Menands, Albany, NY 12241, when the following conditions exist: A. The medical bill(s) originally submitted on Form C-4 (for hospitals, Form UB-92) or HCFA-1500 to the responsible insurance carrier or self-insured employer relates to service(s) rendered on or after October 1, 1994; or for inpatient hospital bills with a discharge date on or after 12-31-96 (for inpatient services with a discharge date prior to 12-31-96 contact your appropriate Dispute Resolution Agent); AND B. The fee(s) billed is in accordance with the fees indicated in the appropriate Fee Schedule; AND C. NO related Form C-7 or C-8.1 has been received or if such form was received, the issue(s) raised thereon by the workers compensation carrier has been ruled on by the Workers Compensation Board, in the health providers favor; AND D. FOR ADMINISTRATIVE AWARD:Treatment was rendered to an injured worker and a medical bill was timely** submitted to the responsible insurance carrier or self-insured employer for payment. A minimum of 45 days has elapsed since the submission of the bill, or 30 days since the date of a final decision by the WCB establishing the carriers or self-insurers liability for the bill; and, no more than 120 days have elapsed since the expiration of the time within which the carrier or self-insurer is required to notify the health provider of non-payment or since the date of expiration of any continuous course of treatment of the claimant. The provider has not received payment or an acceptable written explanation of non-payment (as defined by the WCB) from the responsible carrier. Communicationwith the insurer has been unsuccessful; OR E. FOR ARBITRATION:Treatment was rendered to an injured worker and a medical bill(s) was timely** submitted to the responsible insurance carrier or self-insured employer for payment. Proper payment, in accordance with the appropriate Fee Schedule has NOT been received. The provider has received a written explanation from the carrier or self-insured employer explaining reason(s) for partial or non-payment. Communication with the insurer has failedto resolve the issue(s). A minimum of 45 days has elapsed since the submission of the medical bill(s) to the responsible insurance carrier, or 30 days from the date of a final decision establishing the carriers or self-insurers liability for the bill(s); and, no more than 120 days have elapsed since the date of receipt of notification of non-payment, or the date of expiration of any continuous course of treatment of the claimant. * Required attachments are: Submit ONE original bill with each Request for Administrative Award. For Arbitration, copies of the original medical bill(s) and a copy of the carriers payment explanation is required. If you wish to submit other documents for consideration by the committee, attach them to this form. ** Timely submission of a bill is within 120 days for a hospital and 90 days for all other health providers from the last day of the month in which the service(s) was rendered or 90 days from the last day of the month in which the claimant receives the final treatment in a continuous course of treatment, whichever is later (and the bill was not returned by the post office). PROVIDER :CHECK ONLY ONE REQUEST BOX: (PLEASE TYPE OR PRINT THIS FORM IN BLACK OR BLUE INK ONLY) A. REQUEST FOR ADMINISTRATIVE AWARD B. REQUEST FOR ARBITRATION Carrier has not satisfactorily paid for services rendered as Carrier did not reply with nonpayment explanation or pay shown on the attached medical bill(s). A copy of the carriers for medical services submitted on the attached bill. More payment explanation must be attached. If you wish to submit than 45 days have passed since the date of the medical other documents to be considered by the Committee, attach bill submission or more than 30 days from the receipt of a them to this form. Complete the front and reverse of this related notice establishing carrier/employer liability. form. FILING FOR AN AWARD PRIOR TO THE RESOLUTION Complete the front of this form and Section A on the OF ISSUES RELATED TO C-7, C-8.1 OR RB-89 IS PROHIBITED. reverse. FILING FOR AN AWARD PRIOR TO THE SEE TABLE OF ARBITRATION FEES ON REVERSE. CHECK RESOLUTION OF ISSUES RELATED TO C-7, C-8.1 OR FOR APPROPRIATE FEE, PAYABLE TO CHAIR, WCB, MUST RB-89 IS PROHIBITED. ACCOMPANY EACH REQUEST. FEE IS NOT REQUIRED. DO NOT SUBMIT MORE THAN ONE BILL WITH THIS NUMBER OF MEDICAL BILLS ATTACHED FORM. FEE SUBMITTED CHECK/M.O. NO. $ Outpatient Inpatient Physical Occupational TYPE OF CARE: Medical Chiropractic Psychology Podiatry Osteopathic Hospital Hospital Therapy Therapy Name and Mailing Address of Health Provider(MAXIMUM 30 CHARACTERS) WCB Case Number WCB Authorization Number Name Lines 1&2 Providers WCB Rating Code Address City State Zip Code - Providers Telephone Number Name and Billing Address of Health Provider(MAXIMUM 30 CHARACTERS) ( ) - Name Carrier Case Number Lines 1&2 Address Carrier or Self-Insured Employer I.D. #Date of Accident Zip City State Code - W / / M M D D Y YName and Mailing Address of Carrier (MAXIMUM 30 CHARACTERS County Where Service Was Rendered Name Lines 1&2 Claimants Social Security Address - - City State Zip Code - Name of Claimant (First, Middle Initial, Last Name)Name and Mailing Address of Employer(MAXIMUM 30 CHARACTERS) Name I affirm, under penalty of perjury, that the Lines 1&2 conditions indicated above are true. Address Health Providers Signature Zip City State - Code Date: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, OR SELF-INSURER, ANY INFORMATION CONTAINING ANY FALSE MATERIAL STATEMENT OR CONCEALS ANY MATERIAL FACT SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT. American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 SECTION A: REQUEST FOR ADMINISTRATIVE AWARD - PLEASE COMPLETE THE FOLLOWING 1. Federal Tax I.D. Number 2. Patients Account No. 3. Total Charge 4. Amount Paid 6. Amt. in Dispute SSN EIN $ $ $ SECTION B: REQUEST FOR ARBITRATION - PLEA
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