N.Y. Comp. Codes R. & Regs. tit. 12 § 324.4

Current through Register Vol. 46, No. 45, November 2, 2024

Section 324.4 - PARs confirming consistency with MTG or medical necessity when no MTG

(a) Every insurance carrier, self-insured employer and third-party administrator shall designate a qualified employee or employees as a point of contact for the Board and Treating Medical Providers regarding PARs to confirm consistency with the Medical Treatment Guidelines or medical necessity. Insurance carriers, self-insured employers and third-party administrators shall provide the Chair or his or her designee in the manner prescribed by the Chair with the name and contact information for the point(s) of contact for PARs to confirm consistency with the Medical Treatment Guidelines (PAR: MTG Confirmation) or review for medical necessity (PAR: Non-MTG $1,000 or Under).

Such contact information may include the contacts' direct telephone number(s) and email address(es).

1. If the designated point(s) of contact changes at any time for any reason, the insurance carrier, self-insured employer or third-party administrator shall notify the Chair or his or her designee of such change in the manner prescribed by the Chair.

2. The list of designated points of contact for each insurance carrier, self-insured employer and third-party administrator shall be maintained by the Board electronically. When a treating medical provider submits a PAR electronically, it shall be directed to the appropriate contact person. Any change in the designated contact shall not be effective until the designated contact information has been updated in the Board's electronic records.

3. In the event that an insurance carrier, self-insured employer or third-party administrator fails to so provide the Chair or his or her designee with such name and contact information (in the manner prescribed), or provides incorrect or incomplete contact information during initial registration or when updating pursuant to subparagraph (1) of this subdivision, such insurance carrier, self-insured employer or third-party administrator may be subject to:

i. Orders of the Chair granting any PAR submitted during such time when the name and contact information is missing, incomplete or incorrect; and

ii. Penalties issued pursuant to section 114-a (3) of the Workers' Compensation Law for every case, where a PAR was requested.

(b) Submission by Medical provider

(1) The Treating Medical Provider has the option of submitting a PAR to the insurance carrier, self-insured employer or third-party administrator to confirm that the proposed medical care is consistent with the Medical Treatment Guidelines.

(2) If there is no applicable Medical Treatment Guideline and the cost of the requested treatment is less than $1000 in the aggregate, the Treating Medical Provider has the option of submitting a PAR to the insurance carrier, self-insured employer or third-party administrator for such causally related medically necessary treatment and care. To request to confirm consistency with the Medical Treatment Guidelines (PAR: MTG Confirmation) or medical necessity (PAR: Non-MTG $1,000 or Under), the Treating Medical Provider shall submit the request in the manner prescribed by the Board . The PAR to confirm consistency with the Medical Treatment Guidelines or medical necessity request shall be in the format prescribed by the Chair which may be electronic.

(c) The insurance carrier, self-insured employer or third-party administrator has eight business days from submission of the PAR to confirm consistency with the Medical Treatment Guidelines or medical necessity, and to approve or deny the medical care. The carrier, self-insured employer or third-party administrator shall send the claimant notice of the approval, partial approval or denial of the PAR. Failure to send the claimant such notice may result in penalties under section 25(3)(e), for failure to file a required report with the Board, and section 13-a (6)(a) of the Workers' Compensation Law. In the event the PAR is submitted prior to creation of a workers' compensation case by the Board in accordance with 300.37(a) of this Chapter, the PAR will be promptly reviewed by the Board to identify the proper carrier, self-insured employer or third-party administrator. Upon such identification, the PAR will be directed by the Board to the proper carrier, self-insured employer, or third-party administrator, who shall have 15 calendar days (or 30 calendar days in the event of an IME) to approve, partially approve or deny the request. In the event the PAR is submitted after creation of a workers' compensation case by the Board in accordance with 300.37(a) of this Chapter but prior to filing the mandatory first report of injury pursuant to section 300.22(b) of this Chapter that identifies a third-party administrator responsible for handling the claim, the request may be directed to a third-party administrator that has been designated by the carrier or self-insured employer as handling all or a portion of its workers' compensation claims and identified by the Board as the third-party administrator where such requests will be directed. Such third-party administrator shall have 8 business days to approve, partially approve or deny the request. In the event the PAR is submitted after the mandatory first report of injury pursuant to section 300.22(b) of this Chapter shall become due and no such report has been filed, the Board may issue an Order of the Chair or Notice of Resolution granting the requested treatment.

Unless the PAR is made in a case that has been closed, disallowed or cancelled, where ongoing medical treatment is resolved by an agreement pursuant to section 32 of the Workers' Compensation Law, or controverted in accordance with section 300.22(b)(1)(ii) or (c)(1) of this Chapter, any PAR must be reviewed by the insurance carrier, self-insured employer or third-party administrator Carrier's Physician before it may be denied or partially approved. When an insurance carrier, self-insured employer, or third-party administrator denies or partially approves a PAR, the insurance carrier, self-insured employer, or third-party administrator must also assert any other basis for denial or such basis for denial will be deemed waived. Except as set forth in subparagraph (2) below, all denials or partial approvals must be made by the Carrier's Physician. A partial approval limits the length of time or frequency of the treatment, or authorizes a related but different treatment than that requested in the PAR.

(1) If the insurance carrier, self-insured employer or third-party administrator agrees that the medical care for which a PAR is requested is consistent with the Medical Treatment Guidelines or is medically necessary, it shall respond in the format prescribed by the Chair.

(2) The insurance carrier, self-insured employer or third-party administrator may deny a PAR without review by the Carrier's Physician when a case is closed, disallowed or cancelled, where ongoing medical treatment is resolved by an agreement pursuant to section 32 of the Workers' Compensation Law, or controverted in accordance with section 300.22(b)(1)(ii) or (c)(1) of this Chapter.

(i) Nothing herein shall prohibit an insurance carrier, self-insured employer or third-party administrator from obtaining an opinion from an independent medical examiner.

(ii) When a PAR is denied without review by Carrier's Physician there shall be no review by the Medical Director's Office. A claimant may request review by the Board by filing a Request for Further Action, that demonstrates that the basis for denial is factually inaccurate. The Board may respond to such requests for review by letter or by referral to adjudication, as appropriate in the discretion of the Chair or his or her designee.

(3) A denial of the PAR for reasons other than those set forth in subparagraph (2) of this subdivision, or an approval that concedes medical necessity but does not affirm that the approved medical care will be paid at the fee schedule rate, must be reviewed by the Carrier's Physician. A denial issued by other than a Carrier's Physician is not valid and may be deemed approved by the Board. Invalid denials may be subject to penalties pursuant to sections 13-a (6)(a) and 114-a (3) of the Workers' Compensation Law.

(4) If the insurance carrier, self-insured employer or third-party administrator concedes the medical necessity of the medical care, it may grant without liability, only if the case has been controverted in accordance with section 300.22(b)(1)(ii) or (c)(1) of this Chapter, or the medical care is for a body part or condition that has not been accepted by the insurance carrier, self-insured employer or third-party administrator or established by the Board.

(5) If the insurance carrier, self-insured employer or third-party administrator fails to respond to a PAR within eight business days, the medical care may be deemed approved on the ground that approval was unreasonably withheld and the Chair will issue an order stating that the request is approved. In addition, the carrier, self-insured employer or third-party administrator shall be subject to a penalty pursuant to section 25 (3)(e) of the Workers' Compensation Law.

(d) If a claim is controverted or the time to controvert the claim has not expired, and the insurance carrier, self-insured employer or third-party administrator agrees that the medical care for which a PAR is requested is consistent with the Medical Treatment Guidelines or is medically necessary, such agreement shall not be construed as an admission that the condition for which the PAR is requested is compensable and the insurance carrier, self-insured employer or third-party administrator is not liable for the cost of such treatment unless the claim or condition is established.

(e) For requests made pursuant to (b)(1) herein, if the insurance carrier, self-insured employer or third-party administrator denies that the medical care for which a PAR is requested is consistent with the Medical Treatment Guidelines, the Treating Medical Provider may elect to submit a PAR (PAR: MTG Variance) in accordance with section 324.3 of this Part or submit a request for review .

The Treating Medical Provider may request review of the denial of the PAR within 10 calendar days of the date of the denial by submission of the request in the format prescribed by the Chair which may be electronic. The Medical Director's Office shall rule on whether the medical care is consistent with the Medical Treatment Guidelines and issue a notice of resolution setting forth the ruling and the basis for such ruling . Such notice of resolution is binding and not appealable under Workers' Compensation Law Section 23.

(f) For requests made pursuant to (b)(2) herein, if the insurance carrier, self-insured employer or third-party administrator denies that the medical care for which prior approval is requested is causally related or medically necessary, the Treating Medical Provider may submit a request for review in the format prescribed by the Chair. Upon the request of the Treating Medical Provider, the PAR and denial will be referred to conciliation for a determination as to whether the medical care is causally related and medically necessary. Conciliation shall issue a proposed conciliation decision setting forth the ruling and the basis for such ruling. The claimant and insurance carrier, self-insured employer or third-party administrator may object to the proposed conciliation decision within thirty calendar days in accordance with part 312 of this Chapter. The Treating Medical Provider may not object to the proposed conciliation decision.

(g) An insurance carrier, self-insured employer or third-party administrator may not dispute a bill for medical care on the basis that it was not consistent with the Medical Treatment Guidelines or that it was not causally related or medically necessary, if it has approved a request for prior approval for such medical care or the Board has issued a decision approving the treatment or an Order of the Chair.

(h) An insurance carrier, self-insured employer, or third-party administrator may not object to or deny payment of a medical bill solely because the treating medical provider did not submit a PAR under this section prior to rendering treatment. Denial of a medical bill solely for this reason may result in a penalty pursuant to sections 13-a(6) and 114-a(3).

N.Y. Comp. Codes R. & Regs. Tit. 12 § 324.4

Amended New York State Register March 3, 2021/Volume XLIII, Issue 09, eff. 6/7/2021