Many C-8.1s are resolved in favor of the providers because they are defective, meaning the C-8.1s are not properly completed or timely filed.
Part A Defenses.
The C-8.1 form is divided into two Parts: A and B. Part A requires the carrier to specify the legal reason for its objection to treatment, and to provide information on its conflicting medical evidence, that is, an IME or Peer Review Report. If treatment is being objected to, the carrier must notify the claimant, provider and Board within five days of the objection (e.g. denial of a C-4AUTH request). If the carrier is asserting that the basis for the objection is conflicting medical evidence, such evidence must be supplied with the C-8.1, or if already in the Board file, identified using the Board document identification number. Further, the carrier must provide proof of mailing of notice to the claimant, his attorney and his doctor. See NYCRR 300.23(d).
Part B Defenses.
Part B requires the carrier to specify the legal reason for its objection to bills for treatment. In order to be effective, the C-8.1s must be filed within 45 days of submission of the bill in dispute. The carrier must complete all of the pertinent information, including the date of the bill at issue, the Board document number of said bill, date of treatment, amount of the bill, amount in dispute, and the reason for the objection. If the bill is not in the Board file, the carrier must submit a copy of it with the C-8.1. If the carrier does not object within 45 days, the carrier may be liable for payment of the full amount of the bill up to the amount allowed by the fee schedule. See NYCRR 325-1.25(c).
If the C-8.1s do not contain all of the pertinent information, and are not timely filed, the carrier’s defense of the denial is weakened and the Law Judge is likely to resolve them in favor of the medical provider. In addition, it diminishes the carrier’s chances of being able to depose the claimant’s doctors on the treatment at issue, and does not support a viable record for an appeal. Moreover, when they are resolved in favor of the provider, the carrier can endure costs of expensive (and unnecessary) treatments. Therefore, it is very important that a C-8.1 includes the correct reason for denial of the treatment or the bill, and is timely filed with the Board.