Completing the FROI-04 (denying the claim).
To deny a workers’ compensation claim in New York, the carrier/self insured employer must file an electronic denial. The electronic denial form is mandated by the EDI/eClaims process and designated a “FROI-02” (where the denial is the first document filed by the carrier or self-insured employer) or a SROI-04 (where the carrier/self insured employer has already filed an electronic claim form).
When denying a claim, the carrier/self-insured employer must designate a, EDI denial code (“MTC code”) which is specific to the legal defense raised. For example, the legal defense of “No Accident Arising Out of and In the Course of Employment” is coded as “1A: No Compensable Accident.” It is general practice for the risk professional handling the claim to contact counsel in advance of filing a denial pleading to confirm the legal defenses to be raised and the denial codes to be used.
After the Board notifies the employer (or its insurance carrier) that a workers’ compensation case has been indexed against the employer, the employer may file a notice of controversy (FROI-04) within 25 days from the date of mailing of the notice of indexing. Failure to file the notice of controversy within the prescribed 25 day time limit could bar the employer and its carrier from pleading certain defenses to the claim. WCL § 25(2)(b). Continue reading Denying Claims in New York