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Claims Efficiencies Issue 5
Requesting case copies
If you are not a party of interest on a case and would like to request a case copy:
Parties of interest already have authorized access and may download copies from eCase.
Seeking provider payment after a subsequent decision changes a C-8.1B denial
There are times when a Notice of Objection to a Payment of a Bill for Treatment Provided (Form C-8.1B) decision denies payment of a medical bill because the body part is not established, but a subsequent decision by the Board establishes the body part. When the provider receives a copy of a decision establishing the body part, the provider should contact the payer directly. This may include resubmitting the medical bill together with the subsequent decision. If the payer still does not pay the medical bill, the provider should submit a Request for Decision on Unpaid Medical Bill(s) (Form HP-1.0) to the Board through OnBoard. This is the most direct and efficient way to request intervention by the Board and payment by the payer. Please do not have an attorney submit a Request for Further Action by Legal Counsel (Form RFA-1LC) on your behalf, as this will cause further delays.
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Calculating lost wage benefits
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Lost wage benefits are calculated based on the injured worker’s average weekly wage (AWW) for the 52 weeks before their date of injury or illness, and the degree of disability. To calculate benefits, the Board uses two-thirds of the AWW and then adjusts it by the degree of disability.
For example, if the injured worker’s AWW was $900 and they are 50% disabled, the benefit is $300 per week (2/3 x $900 = $600. $600 x 50% = $300).
If the injured worker only worked for a short period of time before their injury, then the salary of a worker with the same or a similar job title and salary who has worked for the whole year must be used. Additional information is available on the Board’s webpage: Calculating Your Average Weekly Wage (ny.gov)
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Questions?
If you have any questions regarding the guidance in this issue of Efficiency Enhancements, please write to outreach@wcb.ny.gov.
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