Get Himp-1(1/09) - Workers' Compensation Board - New York State - Wcb Ny
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the HIMP-1(1/09) - Workers' Compensation Board - New York State - Wcb Ny online
The HIMP-1(1/09) form is essential for health insurers seeking reimbursement for payments made on behalf of injured workers under New York State's workers' compensation system. This guide provides a step-by-step approach to completing the form online, ensuring a smooth submission process.
Follow the steps to fill out the HIMP-1(1/09) form accurately and effectively.
- Click ‘Get Form’ button to acquire the HIMP-1(1/09) form and open it in the designated editor.
- In Part I, enter the WCB case number associated with the claim. This number identifies your request within the Workers' Compensation Board system.
- Fill in the claimant's Social Security number, ensuring accuracy as this is crucial for processing the reimbursement request.
- Record the date of the accident or injury to link the reimbursement request to the specific incident.
- Input the claimant's name as it appears on official documents to ensure proper identification.
- Include the workers' compensation carrier case number and code, which can typically be found in correspondence with the carrier.
- Specify the reimbursement amount requested alongside the employer's name and the date the payment was made.
- Indicate the date on which you filed the request for reimbursement to document the timeliness of your submission.
- Add the Health Insurer's Claim ID number and the name and address details of the workers' compensation insurance carrier.
- If applicable, fill in the dates for full or partial matches as well as the status of the case, selecting either 'Open' or 'Closed.'
- Record the health insurer's federal tax ID number and telephone number for any follow-up communication.
- After completing Part I, ensure to attach copies of all documentation related to the reimbursement request.
- In Part II, if you're a workers' compensation insurance carrier objecting to the reimbursement, provide necessary justification and documentation.
- In Part III, if requesting arbitration, indicate whether an objection has been mailed and specify details about the arbitration request.
- Once all sections are completed accurately, users can save changes, download, print, or share the completed form as required.
Complete your HIMP-1(1/09) form online today to ensure timely reimbursement.
HIMP stands for Health Insurance Marketplace Plan, which is part of a broader healthcare strategy but is referenced here in the context of workers' compensation evaluations. For the purpose of the HIMP-1(1/09) - Workers' Compensation Board - New York State - Wcb Ny, it outlines specific protocols for assessing workplace injuries and ensuring fair treatment of workers. Knowing this will assist you in navigating the insurance landscape effectively.
Industry-leading security and compliance
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.