Update to Payer Compliance penalty review process

Update to Payer Compliance penalty review process

To better assist payers in developing proper compliance procedures, the Board is clarifying the process when a payer requests review of a penalty proposed by Payer Compliance.

The process for reviewing a penalty issued under WCL §25 is made in accordance with WCL §23 and 12 NYCRR §300.13. Therefore, the provisions of 12 NYCRR 300.13(b)(1)(iii) apply to penalty proceedings on WCL §25 penalties proposed by Payer Compliance.

Upon request for an Administrative Review, the Board may issue an EC-88 notice to the claim administrator requesting specific documentation to support the request for review. The Claim Administrator has 10 days from the date of this notice to file the requested documentation in support of its request for review. Failure to supply the requested documentation may result in the penalty(ies) being upheld. The Board will make no further attempts for the requested information.

Going forward, as of July 1, 2024, any information submitted after the initial Administrative Review Process deadline will be considered new evidence pursuant to 12 NYCRR 300.13(b)(1)(iii). The new evidence must be accompanied by a sworn affidavit documenting the evidence and explaining why it could not have been previously submitted. The Board may accept or deny the newly filed evidence.

The Board will not consider newly filed evidence that is submitted without a sworn affidavit.

Questions? Email monitoring@wcb.ny.gov