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iStock_000014494710XSmallNYSPA's Insurance Committee's Avenues for Seerking Help with Insurance Issues guide

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New York State Department Of Health Standard Clauses For Managed Care Provider/IPA Contracts

Appendix
(Revised 3/1/11)

Notwithstanding any other provision of this agreement, contract, or amendment (hereinafter "the Agreement " or "this Agreement ") the parties agree to be bound by the following clauses which are hereby made a part of the Agreement. Further, if this Agreement is between a Managed Care Organization and an IPA, or between an IPA and an IPA, such clauses must be included in IPA contracts with providers, and providers must agree to such clauses.

A. Definitions For Purposes Of This Appendix

"Managed Care Organization " or "MCO " shall mean the person, natural or corporate, or any groups of such persons, certified under Public Health Law Article 44, who enter into an arrangement, agreement or plan or any combination of arrangements or plans which provide or offer, or which do provide or offer, a comprehensive health services plan.

"Independent Practice Association " or "IPA " shall mean an entity formed for the limited purpose of arranging by contract for the delivery or provision of health services by individuals, entities and facilities licensed or certified to practice medicine and other health professions, and, as appropriate, ancillary medical services and equipment, by which arrangements such health care providers and suppliers will provide their services in accordance with and for such compensation as may be established by a contract between such entity and one or more MCOs. "IPA" may also include, for purposes of this Agreement, a pharmacy or laboratory with the legal authority to contract with other pharmacies or laboratories to arrange for or provide services to enrollees of a New York State MCO.

"Provider " shall mean physicians, dentists, nurses, pharmacists and other health care professionals, pharmacies, hospitals and other entities engaged in the delivery of health care services which are licensed, registered and/or certified as required by applicable federal and state law.

B. General Terms And Conditions

1.This Agreement is subject to the approval of the New York State Department of Health and if implemented prior to such approval, the parties agree to incorporate into this Agreement any and all modifications required by the Department of Health for approval or, alternatively, to terminate this Agreement if so directed by the Department of Health, effective sixty (60) days subsequent to notice, subject to Public Health Law §4403(6)(e). This Agreement is the sole agreement between the parties regarding the arrangement established herein.

2.Any material amendment to this Agreement is subject to the prior approval of the Department of Health, and any such amendment shall be submitted for approval at least thirty (30) days, or ninety (90) days if the amendment adds or materially changes a risk sharing arrangement that is subject to Department of Health review, in advance of anticipated execution. To the extent the MCO provides and arranges for the provision of comprehensive health care services to enrollees served by the Medical Assistance Program, the MCO shall notify and/or submit a copy of such material amendment to DOH or New York City, as may be required by the Medicaid managed care contract between the MCO and DOH (or New York City) and/or the Family Health Plus contract between the MCO and DOH.

3.Assignment of an agreement between an MCO and (1) an IPA, (2) institutional network provider, or (3) medical group provider that serves five percent or more of the enrolled population in a county, or the assignment of an agreement between an IPA and (1) an institutional provider or (2) medical group provider that serves five percent or more of the enrolled population in a county, requires the prior approval of the Commissioner of Health.

4.The Provider agrees, or if the Agreement is between the MCO and an IPA or between an IPA and an IPA, the IPA agrees and shall require the IPA's providers to agree, to comply fully and abide by the rules, policies and procedures that the MCO (a) has established or will establish to meet general or specific obligations placed on the MCO by statute, regulation, or DOH or SID guidelines or policies and (b) has provided to the Provider at least thirty (30) days in advance of implementation, including but not limited to:

    1. oquality improvement/management
    2. outilization management, including but not limited to precertification procedures, referral process or protocols, and reporting of clinical encounter data
    3. omember grievances; and
    4. oprovider credentialing

5.The Provider or, if the Agreement is between the MCO and an IPA, or between an IPA and an IPA, the IPA agrees, and shall require its providers to agree, to not discriminate against an enrollee based on color, race, creed, age, gender, sexual orientation, disability, place of origin, source of payment or type of illness or condition.

6.If the Provider is a primary care practitioner, the Provider agrees to provide for twenty-four (24) hour coverage and back up coverage when the Provider is unavailable. The Provider may use a twenty-four (24) hour back-up call service provided appropriate personnel receive and respond to calls in a manner consistent with the scope of their practice.

7.The MCO or IPA which is a party to this Agreement agrees that nothing within this Agreement is intended to, or shall be deemed to, transfer liability for the MCO's or IPA's own acts or omissions, by indemnification or otherwise, to a provider.

8.Notwithstanding any other provision of this Agreement, the parties shall comply with the provisions of the Managed Care Reform Act of 1996 (Chapter 705 of the Laws of 1996) Chapter 551 of the Laws of 2006, Chapter 451 of the Laws of 2007 and Chapter 237 of the Laws of 2009 with all amendments thereto.

9.To the extent the MCO enrolls individuals covered by the Medical Assistance, and/or Family Health Plus programs, this Agreement incorporates the pertinent MCO obligations under the Medicaid managed care contract between the MCO and DOH (or New York City) and/or the Family Health Plus contract between the MCO and DOH as if set forth fully herein, including:

    1. the MCO will monitor the performance of the Provider or IPA under the Agreement, and will terminate the Agreement and/or impose other sanctions, if the Provider's or IPA's performance does not satisfy standards set forth in the Medicaid managed care and/or Family Health Plus contracts;
    2. the Provider or IPA agrees that the work it performs under the Agreement will conform to the terms of the Medicaid managed care contract between the MCO and DOH (or between the MCO and New York City) and/or the Family Health Plus contract between the MCO and DOH, and that it will take corrective action if the MCO identifies deficiencies or areas of needed improvement in the Provider's or IPA's performance; and
    3. The Provider or IPA agrees to be bound by the confidentiality requirements set forth in the Medicaid managed care contract between the MCO and DOH (or between the MCO and New York City) and/or the Family Health Plus contract between the MCO and DOH.
    4. The MCO and the Provider or IPA agree that a woman's enrollment in the MCO's Medicaid managed care or Family Health Plus product is sufficient to provide services to her newborn, unless the newborn is excluded from enrollment in Medicaid managed care or the MCO does not offer a Medicaid managed care product in the mother's county of fiscal responsibility.
    5. The MCO shall not impose obligations and duties on the Provider or IPA that are inconsistent with the Medicaid managed care and/or Family Health Plus contracts, or that impair any rights accorded to DOH, the local Department of Social Services, or the United States Department of Health and Human Services.
    6. The Provider or IPA agrees to provide medical records to the MCO for purposes of determining newborn eligibility for Supplemental Security Income where the mother is a member of the MCO and for quality purposes at no cost to the MCO.
    7. The Provider or IPA agrees , pursuant to 31 U.S.C.§1352 and CFR Part 93, that no Federally appropriated funds have been paid or will be paid to any person by or on behalf of the Provider/IPA for the purpose of influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the award of any Federal loan, the entering into of any cooperative agreement, or the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. The Provider or IPA agrees to complete and submit the "Certification Regarding Lobbying", Appendix ____ attached hereto and incorporated herein, if this Agreement exceeds $100,000. If any funds other than Federally appropriated funds have been paid or will be paid to any person for the purpose of influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of a member of Congress, in connection with the award of any Federal Contract, the making of any Federal grant, the making of any Federal loan, the entering of any cooperative agreement, or the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement, and the Agreement exceeds $100,000 the Provider or IPA shall complete and submit Standard Form-LLL "Disclosure Form to Report Lobbying," in accordance with its instructions.
    8. The Provider agrees to disclose to MCO on an ongoing basis, any managing employee that has been convicted of a misdemeanor or felony related to the person's involvement in any program under Medicare, Medicaid or a Title XX services program (Block grant programs)
    9. The Provider agrees to monitor its employees and staff against the List of Excluded Individuals and Entities (LEIE) and excluded individuals posted by the OMIG on its Website.
    10. The Provider agrees to disclose to MCO complete ownership, control, and relationship information.
    11. Provider agrees to obtain for MCO ownership information from any subcontractor with whom the provider has had a business transaction totaling more than $25,000, during the 12 month period ending on the date of the request made by SDOH, OMIG or DHHS. The information requested shall be provided to MCO within 35 days of such request.

10.The parties to this Agreement agree to comply with all applicable requirements of the Federal Americans with Disabilities Act.

11.The Provider agrees, or if the Agreement is between the MCO and an IPA or between an IPA and an IPA, the IPA agrees and shall require the IPA's providers to agree, to comply with all applicable requirements of the Health Insurance Portability and Accountability Act; the HIV confidentiality requirements of Article 27-F of the Public Health Law and Mental Hygiene Law§33.13.

C. Payment; Risk Arrangements

1.Enrollee Non-liability. Provider agrees that in no event, including, but not limited to, nonpayment by the MCO or IPA, insolvency of the MCO or IPA, or breach of this Agreement, shall Provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against a subscriber, an enrollee or person (other than the MCO or IPA) acting on his/her/their behalf, for services provided pursuant to the subscriber contract or Medicaid Managed Care contract or Family Health Plus contract and this Agreement, for the period covered by the paid enrollee premium. In addition, in the case of Medicaid Managed Care, Provider agrees that, during the time an enrollee is enrolled in the MCO, he/she/it will not bill the New York State Department of Health or the City of New York for Covered Services within the Medicaid Managed Care Benefit Package as set forth in the Agreement between the MCO and the New York State Department of Health. In the case of Family Health Plus, Provider agrees that, during the time an enrollee is enrolled in the MCO, he/she/it will not bill the New York State Department of Health for Covered Services within the Family Health Plus Benefit Package, as set forth in the Agreement between the MCO and the New York State Department of Health. This provision shall not prohibit the provider, unless the MCO is a managed long term care plan designated as a Program of All-Inclusive Care for the Elderly (PACE), from collecting copayments, coinsurance amounts, or permitted deductibles, as specifically provided in the evidence of coverage, or fees for uncovered services delivered on a fee-for-service basis to a covered person provided that Provider shall have advised the enrollee in writing that the service is uncovered and of the enrollee's liability therefore prior to providing the service. Where the Provider has not been given a list of services covered by the MCO, and/or Provider is uncertain as to whether a service is covered, the Provider shall make reasonable efforts to contact the MCO and obtain a coverage determination prior to advising an enrollee as to coverage and liability for payment and prior to providing the service. This provision shall survive termination of this Agreement for any reason, and shall supersede any oral or written agreement now existing or hereafter entered into between Provider and enrollee or person acting on his or her behalf.

2.Coordination of Benefits (COB). To the extent otherwise permitted in this Agreement, the Provider may participate in collection of COB on behalf of the MCO, with COB collectibles accruing to the MCO or to the provider. However, with respect to enrollees eligible for medical assistance, or participating in Child Health Plus or Family Health Plus, the Provider shall maintain and make available to the MCO records reflecting COB proceeds collected by the Provider or paid directly to enrollees by third party payers, and amounts thereof, and the MCO shall maintain or have immediate access to records concerning collection of COB proceeds.

3.If the Provider is a health care professional licensed, registered or certified under Title 8 of the Education Law, the MCO or the IPA must provide notice to the Provider at least ninety (90) days prior to the effective date of any adverse reimbursement arrangement as required by Public Health Law §4406-c(5-c). Adverse reimbursement change shall mean a proposed change that could reasonably be expected to have a material adverse impact on the aggregate level of payment to a health care professional. This provision does not apply if the reimbursement change is required by law, regulation or applicable regulatory authority; is required as a result of changes in fee schedules, reimbursement methodology or payment policies established by the American Medical Association current procedural terminology (CPT) codes, reporting guidelines and conventions; or such change is expressly provided for under the terms of this Agreement by the inclusion or reference to a specific fee or fee schedule, reimbursement methodology or payment policy indexing scheme.

4.The parties agree to comply with and incorporate the requirements of Physician Incentive Plan (PIP) Regulations contained in 42 CFR §438.6(h), 42 CFR §422.208, and 42 CFR § 422.210 into any contracts between the contracting entity (provider, IPA, hospital, etc.) and other persons/entities for the provision of services under this Agreement. No specific payment will be made directly or indirectly under the plan to a physician or physician group as an inducement to reduce or limit medically necessary services furnished to an enrollee.

 5.The parties agree that a claim for home health care services following an inpatient hospital stay cannot be denied on the basis of medical necessity or a lack of prior authorization while a utilization review determination is pending if all necessary information was provided before a member's inpatient hospital discharge, consistent with Public Health Law §4903.

D. Records; Access

1.Pursuant to appropriate consent/authorization by the enrollee, the Provider will make the enrollee's medical records and other personally identifiable information (including encounter data for government-sponsored programs) available to the MCO (and IPA if applicable), for purposes including preauthorization, concurrent review, quality assurance, (including Quality Assurance Reporting Requirements (QARR)), payment processing, and qualification for government programs, including but not limited to newborn eligibility for Supplemental Security Income (SSI) and for MCO/Manager analysis and recovery of overpayments due to fraud and abuse. The Provider will also make enrollee medical records available to the State for management audits, financial audits, program monitoring and evaluation, licensure or certification of facilities or individuals, and as otherwise required by state law. The Provider shall provide copies of such records to DOH at no cost. The Provider (or IPA if applicable) expressly acknowledges that he/she/it shall also provide to the MCO and the State (at no expense to the State), on request, all financial data and reports, and information concerning the appropriateness and quality of services provided, as required by law. These provisions shall survive termination of the contract for any reason.

 2.When such records pertain to Medicaid or Family Health Plus reimbursable services the Provider agrees to disclose the nature and extent of services provided and to furnish records to DOH and/or the United States Department of Health and Human Services, the County Department of Social Services, the Comptroller of the State of New York, the Office of the Medicaid Inspector General, the New York State Attorney General, and the Comptroller General of the United States and their authorized representatives upon request. This provision shall survive the termination of this Agreement regardless of the reason.

 3.The parties agree that medical records shall be retained for a period of six (6) years after the date of service, and in the case of a minor, for three (3) years after majority or six (6) years after the date of service, whichever is later, or for such longer period as specified elsewhere within this Agreement. This provision shall survive the termination of this Agreement regardless of the reason.

 4.The MCO and the Provider agree that the MCO will obtain consent directly from enrollees at the time of enrollment or at the earliest opportunity, or that the Provider will obtain consent from enrollees at the time service is rendered or at the earliest opportunity, for disclosure of medical records to the MCO, to an IPA or to third parties. If the Agreement is between an MCO and an IPA, or between an IPA and an IPA, the IPA agrees to require the providers with which it contracts to agree as provided above. If the Agreement is between an IPA and a provider, the Provider agrees to obtain consent from the enrollee if the enrollee has not previously signed consent for disclosure of medical records.

E. Termination and Transition

1.Termination or non-renewal of an agreement between an MCO and an IPA, institutional network provider, or medical group Provider that serves five percent or more of the enrolled population in a county, or the termination or non-renewal of an agreement between an IPA and an institutional Provider or medical group Provider that serves five percent or more of the enrolled population in a county, requires notice to the Commissioner of Health. Unless otherwise provided by statute or regulation, the effective date of termination shall not be less than 45 days after receipt of notice by either party, provided, however, that termination, by the MCO may be effected on less than 45 days notice provided the MCO demonstrates to DOH's satisfaction prior to termination that circumstances exist which threaten imminent harm to enrollees or which result in Provider being legally unable to deliver the covered services and, therefore, justify or require immediate termination.

 2.If this Agreement is between the MCO and a health care professional, the MCO shall provide to such health care professional a written explanation of the reasons for the proposed contract termination, other than non-renewal, and an opportunity for a review as required by state law. The MCO shall provide the health care professional 60 days notice of its decision to not renew this Agreement.

 3.If this Agreement is between an MCO and an IPA, and the Agreement does not provide for automatic assignment of the IPA's Provider contracts to the MCO upon termination of the MCO/IPA contract, in the event either party gives notice of termination of the Agreement, the parties agree, and the IPA's providers agree, that the IPA providers shall continue to provide care to the MCO's enrollees pursuant to the terms of this Agreement for 180 days following the effective date of termination, or until such time as the MCO makes other arrangements, whichever first occurs. This provision shall survive termination of this Agreement regardless of the reason for the termination.

 4.Continuation of Treatment. The Provider agrees that in the event of MCO or IPA insolvency or termination of this contract for any reason, the Provider shall continue, until medically appropriate discharge or transfer, or completion of a course of treatment, whichever occurs first, to provide services pursuant to the subscriber contract, Medicaid Managed Care contract, or Family Health Plus contract, to an enrollee confined in an inpatient facility, provided the confinement or course of treatment was commenced during the paid premium period. For purposes of this clause, the term "provider" shall include the IPA and the IPA’s contracted providers if this Agreement is between the MCO and an IPA. This provision shall survive termination of this Agreement.

5.Notwithstanding any other provision herein, to the extent that the Provider is providing health care services to enrollees under the Medicaid Program and/or Family Health Plus, the MCO or IPA retains the option to immediately terminate the Agreement when the Provider has been terminated or suspended from the Medicaid Program.

6.In the event of termination of this Agreement, the Provider agrees, and, where applicable, the IPA agrees to require all participating providers of its network to assist in the orderly transfer of enrollees to another provider.

F. Arbitration

1.To the extent that arbitration or alternative dispute resolution is authorized elsewhere in this Agreement, the parties to this Agreement acknowledge that the Commissioner of Health is not bound by arbitration or mediation decisions. Arbitration or mediation shall occur within New York State, and the Commissioner of Health will be given notice of all issues going to arbitration or mediation, and copies of all decisions.

G. IPA-Specific Provisions

1.Any reference to IPA quality assurance (QA) activities within this Agreement is limited to the IPA’s analysis of utilization patterns and quality of care on its own behalf and as a service to its contract providers.

 

AG's Office Wins Settlement Regarding MH Parity (April 22, 2014)

AG's Office Wins Settlement Regarding MH Parity:

MVP Patients May Be Able to Reverse Treatment Denials

by Ann Altoonian, PsyD
Member, NYSPA Insurance Committee

There was news last week about a very important settlement of a case that the NYS Attorney General’s office pursued against MVP regarding violations of mental health parity laws. If you have not read about this landmark “first” case of a state AG office succeeding in proving violation of parity (in this case, it was the NYS MH Parity law, or “Timothy’s Law”), here are some links to news articles:

·         http://www.democratandchronicle.com/story/money/business/2014/03/19/mvp-health-care-settlement-attorney-general/6620457/

·         http://www.behavioral.net/article/new-york-ag-strikes-hard-against-parity-violations

I had some questions for the AG’s office regarding the MVP settlement and contacted Michael Reisman of the Health Care Bureau. He was kind enough to speak with me on the phone last week. My questions to Mr. Reisman are outlined below, followed by his answers.

---

Question 1: The changes MVP must make (i.e., must tell their contractor, ValueOptions, to make) from now on that are mandated by this settlement are excellent. I also understand that, under the terms of the settlement, MVP patients who have had treatment denials after their mental health provider filed the necessary treatment review information (e.g., OTRs, prior authorization calls) are eligible to have their cases reconsidered. What about cases where patients and providers, because of “learned helplessness,” privacy concerns, or other factors, did not even take the step to complete OTR’s or other demands by the company?

My understanding of Mr. Reisman’s responses (designated “AA via MR”): If a patient from a “fully-funded” MVP plan has been denied further treatment in January 2011 or later, they are eligible to be considered for review (“fully funded” means members of the community are insured by the plan, as opposed to “self-funded” plans where the employer provides the funding and only employees and dependents are being covered). Cases that are eligible for the settlement-designated independent review are those where patients had necessary treatment denied and did not get to the point where they could file an external appeal. Patients are eligible to have an independent review of the medical necessity of their treatment whether or not the provider/patient completed an OTR, authorization call, or internal review.

Question 2: Will patients or providers be notified if they are eligible for the independent review?

AA via MR: Some patients will automatically be contacted, but all patients who had treatment denied can contact MVP directly via member services. In addition, it would be helpful for the AG’s office to know that a patient is pursuing the issue with MVP, and this can be done by calling the AG’s Health Care Bureau Helpline at 800-428-9071. This is to insure there is no miscommunication with MVP. Patients should report the basics to the paralegal who answers the helpline, including timeframe, and number of sessions. They should also report the whether they had to pay out of pocket.  In that case, they should name the provider and the amount.

Question 3: Who will be doing the independent reviews?

AA via MR: The reviews will be done the same way that current external reviews are done here in NYS. They will be overseen by the NYS Department of Financial Services (formerly the NYS Insurance Department) and done by one of three contractors that the office uses for the purpose of external reviews.

Question 4: Our APA Practice Organization has chosen to work on the same types of parity violations, as shown by the request they have put out to clinicians that I forwarded to you earlier.  Any comments about this action?

AA via MR: There is some outdated information and a typo in the APAPO request in terms of when the Federal Parity Act, or MHPAEA, applies to insurance. The typo is found in the statement about the number of employees that define a small employer, which is 50, not 500. However, as of the implementation of the final rule of the MHPAEA (effective officially on 7/1/14), if the insurance plan is “fully funded” as opposed to self-funded by the business, the MHPAEA applies even if they have 50 employees or less. The ACA brought parity to employer and small group plans; the final rule of Federal Parity makes it apply to individual plans.

Question 5: I see that, going forward, MVP/VO subscribers are to be charged the lower, primary care copayment for their outpatient visits to most behavioral health professionals. Many insurance companies have been using-- and continue to use-- the higher specialist copayment for outpatient mental health visits, despite the inclusion of language in the MHPAEA to the contrary. Thinking about how this problem persists, I wonder: What made MVP change its policy?

AA via MH: To clarify, going forward, the primary care copay will be charged for behavioral services, except for those delivered by a Medical Doctor (MD/DO). However-- and this has always been true of NYS insurance law-- any MD specialist can apply to be designated a PCP for particular patients. If the PCP copay is for routine outpatient care, then the same fee should apply for routine outpatient mental health visits. The AG’s office shared their interpretation of the law as part of their discussions with MVP, that charging the higher, specialist copayment for psychotherapy can deter members from seeking treatment, and got MVP to see it their way.

Question 6: Is the NYS employees’ health insurance (the Empire Plan) subject to the Federal Parity law, or did it opt-out?

AA via MH: Originally, the Empire Plan opted-out of Federal Parity, but reconsidered that decision. Since about 2012, they are not opted-out.

---

In closing, I asked Mr. Reisman about the status of the GVPA complaint regarding Excellus.  He said the investigation is ongoing.

 

This is complicated stuff, but there are two crucial takeaways regarding this settlement: First, encourage your patients who were affected by treatment denials/sessions running out to take action. Second, contact APAPO about other companies where you and your patients are running into coverage denials. 

NYS Workers Compensation - Workers' Compensation Board Mandates Electronic Claims Filing Process (eClaims)

New York State
Workers' Compensation Board
OFFICE OF THE CHAIR
20 Park Street   Albany, New York 12207

Governor Andrew M. Cuomo

Subject No. 046-477

Date: March 5, 2012

Introduction

The Board is adopting a national standard for claim administrators to electronically submit employer claims data. The standard is the International Association of Industrial Accident Boards and Commissions' (IAIABC) Claims Electronic Data Interchange (EDI) Release 3.0. This electronic filing of claims data will be implemented in phases, beginning in spring 2013, and will provide timely, accurate, and credible electronic reporting.

More than 30 states currently use or are actively planning to use the IAIABC EDI standard for claim submissions. Most national carriers already utilize the standard in those jurisdictions. The technology is recognized as the national best practice for First Report of Injury/Subsequent Report of Injury (FROI/SROI), and has a proven track record.

The Board intends to collaborate with claim administrators in the workers' compensation industry to ensure that this transition to electronic filing is as seamless as possible. Electronic claims filing supports the Board's continuing effort to improve services to injured workers of New York and their employers. In fact, based on the experience of other states that have implemented the IAIABC standard, the Board anticipates that its adoption in New York will yield significant benefits, including:

  • Improving the timely delivery of benefits to injured workers
  • Providing seamless processing of information from the initial claims reporting source to the jurisdiction
  • Providing a single, consistent data format
  • Reducing paper handling costs to system participants outside the Board, i.e., handling, completing, and shipping
  • Reducing high costs to the Board for handling, processing, and scanning paper documents as well as certain data entry costs
  • Simplifying the Board's case assembly process
  • Reducing duplicative claim form filings
  • Decreasing the time it takes for claims information to be available to system stakeholders. Claim administrators filings would be available via ¹eCase within 24 hours of receipt.
  • Increasing the quality and timeliness of information received by the Board. Over time, this benefit will increase efficiencies and drive performance in the processing of claims for all participants, with a direct benefit to injured workers.
  • Increasing the availability of data for policy decisions

Implementation Plan

Collaboration and communication between stakeholders and the Board will be essential to a successful transition from a paper to an electronic claims reporting environment. As a first step in stakeholder communication, the Board has developed a presentation that provides an overview of electronic claims filing, including the benefits that result from the adoption of an electronic reporting standard.

This presentation includes:

  • Results of best practices outreach and research -- including the feedback received from other states on training, implementation and timelines
  • Brief overview of the IAIABC
  • eClaims benefits
  • Mapping WCB forms to eClaims
  • Options for submissions
  • Project milestones
  • Communication and training plan encouraging stakeholder involvement

The Board invites all stakeholders to review the presentation. To achieve a seamless transition to electronic claims filing, the Board would like more information from the claim administrator community. At the end of the presentation, there is a link to a questionnaire. It is an opportunity for claim administrators to give input about their familiarity with electronic claim filing and adopting the IAIABC standard in other jurisdictions. The Board will use this information to develop a communication strategy that addresses the various needs of stakeholders in this ongoing process.

The Board will establish and support transparent and continuous two-way communications with all stakeholders impacted by this transition. As a first step, the Board's Office of Stakeholder Outreach and Education has recently requested that insurance carriers, self-insurers and third party administrators provide their departmental contact information. This contact information will enhance the Board's capacity to directly interact with appropriate individuals from these stakeholders. Please This email address is being protected from spambots. You need JavaScript enabled to view it. if you need another copy of the contact information form.

For more information on the IAIABC Claims Release 3.0, please visit the EDI Implementation Guide section of the IAIABC website at: www.iaiabc.org .

Questions related to this announcement can be directed to: This email address is being protected from spambots. You need JavaScript enabled to view it. . As the Board publishes more information on this initiative it will be posted on our eClaims web page.

The Board looks forward to working with stakeholders during the transition to this electronic claims submission process.

Robert E. Beloten
Chair

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