N.Y. Comp. Codes R. & Regs. Tit. 12 §§ 325-1.25

Current through Register Vol. 46, No. 43, October 23, 2024

Section 325-1.25 - Payment of and objections to medical bills

(a) Obligation and liability of employer or insurance carrier (or third-party administrator) to provide Medical Care.

(1) The employer or insurance carrier (or third-party administrator) is required to promptly provide the claimant with such Medical Care, for such period as the nature of the injury, illness, or occupational disease, or process of recovery may require. Medical Care means symptomatic, palliative, maintenance treatment, services, or supplies. When the Medical Care is to or for a part of the body or condition covered by the Medical Treatment Guidelines as set forth in section 324.2(a) of this Title, the employer or insurance carrier (or third-party administrator) is required to provide such Medical Care which is consistent with the Medical Treatment Guidelines or, if applicable, an approved variance from such guidelines.

(2) The employer or insurance carrier (or third-party administrator) is liable for the payment of medically necessary care, services, and supplies to the claimant when it has accepted the claim or the claim has been established as compensable by the Board. When the Medical Care is to or for a part of the body covered by the Medical Treatment Guidelines and the claim has been accepted or established as compensable, the employer or insurance carrier (or third-party administrator) shall be obligated to pay for all Medical Care, in the amount set forth in the applicable fee schedule, or in any other amount as agreed to by the Treating Medical Provider and payor, that is:

(i) within the criteria of the medical treatment guidelines incorporated by reference pursuant to section 324.2(a) of this Title and is based on correct application of such guidelines;

(ii) within a proper variance from the Medical Treatment Guidelines in accordance with the requirements of section 324.3(a) (2), or has been authorized pursuant to section 325-1.4 or Part 441of this Title;

(iii) agreed to by the employer or insurance carrier (or third-party administrator); or

(iv) as ordered by the Board pursuant to statute or regulation.

The employer or insurance carrier (or third-party administrator) shall not be obligated to pay for any Medical Care that is not within the criteria of the Medical Treatment Guidelines or is not based on correct application of the Medical Treatment Guidelines, except if a variance has been approved by the employer, insurance carrier (or third-party administrator), or Board in accordance with section 324.3 of this Title or as ordered by the Board pursuant to statute or regulation.

(b) Submission of bills for Medical Care.

(1) Physicians, podiatrists, chiropractors, psychologists, nurse practitioners, physician assistants, licensed clinical social workers, physical therapists, occupational therapists and acupuncturists authorized by the Chair to provide treatment and care under the Workers' Compensation Law to a claimant or other legally permitted providers of Medical Care shall submit bills for Medical Care in the format prescribed by the Chair (which may be electronic) and as set forth in section 325-1.3 of this Subpart. Bills shall be submitted to the employer or insurance carrier (or third-party administrator) within 120 days from the day the Medical Care was rendered. Bills submitted in any other format or outside this time requirement shall not be eligible for an award by the Chair under the provisions of the Workers' Compensation Law as described herein. When Medical Care was rendered prior to January 1, 2020, the bill for such care shall be submitted within 120 days from January 1, 2020 (April 30, 2020).

(2) Hospitals shall submit bills for out-patient hospital services to the employer or insurance carrier (or third-party administrator) using the New York State Universal Data Set specification as described in 10 NYCRR section 400.18 and Appendices C-2 and C-3 and such additional specifications as are approved by the Commissioner of Health. Bills shall be submitted within 120 days from the last day of Medical Care. Bills submitted in any other format or outside this time requirement shall not be eligible for an award by the Chair under the provisions of the Workers' Compensation Law as described herein.

(3) Notwithstanding the foregoing, upon an application in writing to the Chair, the Chair may for good cause shown excuse a delay in the submission of the bill to the insurance carrier or employer (or third-party administrator).

(c) Payment of bills for Medical Care.

(1) The employer or insurance carrier (or third-party administrator), within 45 days after the bill has been received shall pay the bill or shall notify the physician, occupational or physical therapist, podiatrist, chiropractor, psychologist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital, or other provider of Medical Care, the claimant and claimant's attorney if applicable, and the Board in the format prescribed by the Chair (which may be electronic) for such purpose that the bill is not being paid and the reasons for non-payment. If the employer or insurance carrier (or third-party administrator) objects to payment of all or part of the bill for reasons concerning its legal liability for payment, the legal objections shall be made in the format prescribed by the Chair for such purpose and submitted to the physician, occupational or physical therapist, podiatrist, chiropractor, psychologist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital, or other provider of Medical Care, the claimant and claimant's attorney if applicable, and the Board simultaneously with any other objections to the bill. If the employer or insurance carrier (or third-party administrator) objects to payment of all or part of the bill for reasons concerning the value of the treatment performed or the amount billed, the valuation objections shall be made in the format prescribed by the Chair for that purpose and submitted to the physician, occupational or physical therapist, podiatrist, chiropractor, psychologist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital, or other provider of Medical Care, the claimant and claimant's attorney if applicable, and the Board simultaneously with any other objections to the bill. However, if the only objection is that the amount billed for the particular Current Procedural Terminology (CPT) code is in excess of the appropriate fee schedule for the region where the services were provided, the insurance carrier or employer (or third-party administrator) may instead file its explanation of benefits form. If the employer or insurance carrier (or third-party administrator) objects to payment of all or part of the bill for one or more of the Medical Treatment Guidelines objections set forth in paragraph (7) of this subdivision, the objections shall be placed in the format prescribed by the Chair (which may be electronic), along with the basis for the objection, and submitted to the physician, occupational or physical therapist, podiatrist, chiropractor, or psychologist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital, or other provider of Medical Care, the claimant and claimant's attorney if applicable, and the Board simultaneously with any other objections to the bill.

(2) If the employer or insurance carrier (or third-party administrator) objects to only a portion of the bill submitted, it shall pay the uncontested portion within 45 days and file objections to the remaining portion as indicated herein.

(3) If the employer or insurance carrier (or third-party administrator) has not objected in the manner described herein to the payment of the bill within 45 days of submission, it shall be liable for payment of the full amount billed up to the maximum amount established in the applicable fee schedule. The Board shall not review any objection made thereafter.

(4) Legal, valuation, and Medical Treatment Guidelines objections shall be made simultaneously in the format prescribed by the Chair (which may be electronic).

(5) Valuation objections as to the amount of the bill include, but are not limited to, contentions that the bill is excessive and not in accordance with the pertinent fee schedule; has not been properly pro-rated or apportioned between providers; involves concurrent, duplicative, or overlapping services; uses improper current procedural terminology codes; is not in accordance with the Ground Rules limitation in the appropriate official workers' compensation fee schedule; is rendered too frequently; involves unnecessary or excessive hospitalization; or involves a physician, occupational or physical therapist, podiatrist, chiropractor, psychologist, nurse practitioner, physician assistant, licensed clinical social worker or acupuncturist treating outside the scope of practice.

(6) Legal objections as to the liability of the employer or insurance carrier (or third-party administrator) to pay include, but are not limited to, contentions that the claim has been controverted and liability has not been resolved; prior authorization for the special medical service was not granted; treatment was not causally related to the compensable injury; treatment provided was outside of the preferred provider organization; the medical report was not timely filed or was legally defective; the medical appliance, program, or provider is not authorized under the Workers' Compensation Law; or the bill is for evidentiary purposes and not for treatment. Pursuant to Workers' Compensation Law section 13(a), raising the issue of liability under Workers' Compensation Law section 25-a is not a valid legal objection to payment of a bill for treatment. A legal objection that was not properly raised in response to any applicable prior authorization request will be denied. The employer or insurance carrier (or third-party administrator) shall attach or identify the denial made to any applicable prior authorization request to its legal objection.

(7) The Medical Treatment Guidelines objections as to the liability of the employer or insurance carrier (or third-party administrator) to pay are:

(i) the treatment is not consistent with the Medical Treatment Guidelines and a variance was not requested or approved by the employer or insurance carrier (or third-party administrator), or the Board before the Medical Care was rendered;

(ii) the physician, podiatrist, chiropractor, psychologist, nurse practitioner, licensed clinical social worker, or hospital varied from the Medical Treatment Guidelines, the physician, podiatrist, chiropractor, psychologist, nurse practitioner, licensed clinical social worker, hospital, or other provider of Medical Care, requested and received approval for a variance from the employer or insurance carrier (or third-party administrator) or the Board before the Medical Care was rendered but provided Medical Care other than what was covered by the variance; or

(iii) the physician, occupational or physical therapist, podiatrist, chiropractor, psychologist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital or other legally permitted Medical Care provider misapplied the Medical Treatment Guidelines.

(iv) A Medical Treatment Guideline objection that was not properly raised in response to any applicable prior authorization request will be denied. The employer or insurance carrier (or third-party administrator) shall attach or identify the denial made to any applicable prior authorization request to its legal objection.

(d) Administrative award: a remedy for non-payment of bills when no timely valuation objections are raised.

(1) Chair authorized physicians, podiatrists, chiropractors, psychologists, nurse practitioners, physician assistants, licensed clinical social workers, acupuncturists, occupational or physical therapists, and other legally permitted providers of Medical Care, or hospitals providing services to claimants who have timely submitted bills for payment to the insurance carrier or employer (or third-party administrator) and who have not been paid in full or in part or received notice in the format prescribed by the Chair (which may be electronic) for the purpose of advising of a valuation reason for non-payment within the time prescribed above, may apply to the Chair the prescribed format (which may be electronic) for an administrative award pursuant to the provisions of Workers' Compensation Law sections 13-g(1), 13-k(6), 13-l(6) and 13-m(7). Such request shall be submitted no earlier than 45 days from the date of the submission of the bill or 30 days from the date of the Workers' Compensation Law Judge or conciliation decision, or if appeal, Board Panel decision establishing the insurance carrier's or employer's (or third-party administrator's) liability for the bill, and within 120 days from the later of:

(i) the date of receipt of notification of nonpayment; or

(ii) the expiration of the time within which the insurance carrier or employer (or third-party administrator) is required to notify the physician, self-employed occupational or physical therapist, podiatrist, chiropractor, psychologist, or hospital of nonpayment.

(2) Notwithstanding the foregoing, upon a written application of the physician, occupational or physical therapist, podiatrist, chiropractor, psychologist, nurse practitioners, physician assistants, licensed clinical social workers, acupuncturists, hospital, or other provider of Medical Care, the Chair may for good cause shown excuse a delay in the submission of the request for an administrative award

(3)

(i) The Board will not accept any request for an administrative award until thirty days after all issues duly and timely raised by the employer or insurance carrier (or third-party administrator) with respect to its legal liability for payment and/or any Medical Treatment Guidelines objections set forth in paragraph (c)(7) of this section have been finally determined adversely to it.

(ii) A provider may only submit one request for an administrative award for each date of service. A request for administrative award that includes a date of service that was included on a previously submitted request for administrative award will be rejected.

(4) All requests for administrative awards shall be submitted to the Chair or his or her designee in the format prescribed for such purpose and certifies the following information:

(i) the bill was timely submitted to the employer or insurance carrier (or third-party administrator) and the bill was not returned;

(ii) the employer or insurance carrier (or third-party administrator) did not submit payment within 45 days after the bill was submitted or within 30 days after all questions duly and timely raised related to the employer or insurance carrier (or third-party administrator)'s liability therefore was finally determined adversely to it;

(iii) the employer or insurance carrier (or third-party administrator) did not raise valuation issues in the format prescribed by the Chair objecting to payment of the bill;

(iv) the bill conforms to the fee schedule, if any, promulgated by the chair for treatment rendered; and

(v) the bill was submitted in the format prescribed by the Chair (which may be electronic) and as set forth in section 325-1.3 of this Subpart, or the form prescribed for outpatient hospital bills by the Commissioner of Health.

(5) The Board will reject incomplete requests for an administrative award. When information regarding a workers' compensation claim that is included on a request for administrative award does not match the information in the Board's electronic case system, the request may be rejected by the Board and the provider will be directed to review such information with his or her patient.

(6) Upon receipt by the Chair or his or her designee of a completed request for an administrative award, the request shall be examined to determine if it is in compliance with the requirements of this section. If the request is not in compliance with the requirements of this section, the request will be rejected by the Board with an explanation of why the request is being rejected. If the request is in full compliance with the requirement of this section, a notice of decision on the Chair prescribed form signed by the Chair or the Chair's designee will propose an administrative award for the Medical Care rendered not in excess of the fee schedule, if any, to the authorized physician, podiatrist, chiropractor, psychologist, occupational or physical therapist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital or other provider of Medical Care. The Chair prescribed form for the notice of decision will be sent to all parties of interest, notifying them of the proposed administrative award and the proposed filing date. The proposed filing date shall be at least 30 days after the date of the proposed administrative award.

(7) Any party in interest may submit a written objection in the format prescribed by the Chair (which may be electronic) to the proposed award on or before the proposed filing date. All documents or other evidence supporting the objection shall be submitted together with the written objection. If there is no written objection received prior to the proposed filing date, the proposed award will become final on the proposed filing date. If an objection is received from any party before the proposed filing date, the objection shall be reviewed by the Chair or the Chair's designee, who shall make a decision on the request for an award based upon the documents and other evidence submitted. Upon review, a determination on reconsideration shall be sent to all parties in interest.

(8) Interest on any administrative award made to a physician, self-employed occupational or physical therapist, podiatrist, chiropractor, psychologist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, or other provider of Medical Care, pursuant to this section shall be paid in accordance with the provisions of section 300.19 of this Title.

(e) Arbitration award: a remedy for non-payment of bills when timely valuation objections are raised.

(1) Chair authorized physicians, podiatrists, chiropractors, or psychologists, occupational or physical therapists, nurse practitioners, physician assistants, licensed clinical social workers, acupuncturists, hospitals or other legally permitted providers of Medical Care providing services to claimants who have timely submitted bills for payment to the employer or insurance carrier (or third-party administrator) in compliance with the provisions herein and have received a response in the format prescribed by the Chair (which may be electronic) from the employer or insurance carrier (or third-party administrator) advising of a valuation reason for non-payment of the bill in full or in part within the time prescribed in this section, may apply to the Chair for arbitration the format prescribed if the parties cannot agree as to the value of the services rendered.

(2) Arbitration shall be requested solely at the option of the authorized physician, podiatrist, chiropractor, psychologist, occupational or physical therapist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital or other provider of Medical Care.

(3) Notwithstanding the foregoing, upon a written application of the authorized physician, podiatrist, chiropractor, psychologist, occupational or physical therapist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital or other provider of Medical Care, the Chair may for good cause shown excuse a delay in the submission of the request for arbitration.

(4) The Chair will not accept any request for an arbitration award until thirty days after all issues duly and timely raised by the employer or insurance carrier (or third-party administrator) with respect to its legal liability for payment and/or any Medical Treatment Guidelines objections set forth in paragraph (c)(7) of this section have been finally determined adversely to it.

(f) Adjudication decision: a resolution for non-payment of bills when legal objections and medical treatment guidelines are raised.

(1) If the employer or insurance carrier (or third-party administrator) objects to payment of all or part of the bill for Medical Care rendered for reasons concerning its legal liability for payment and/or the Medical Treatment Guidelines as set forth in paragraph (c)(7) of this section and raises legal and/or Medical Treatment Guidelines objections in the format prescribed by the Chair (which may be electronic) for such purpose as indicated herein, the objection will be reviewed by the Board and a decision rendered on the issue of legal liability and/or the Medical Treatment Guidelines objections. The decision shall be filed with the parties including the authorized physician, podiatrist, chiropractor, psychologist, occupational or physical therapist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital or other provider of Medical Care.

(2) If legal liability and/or Medical Treatment Guidelines objection for the service is found in favor of the physician, podiatrist, chiropractor, psychologist, occupational or physical therapist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital or other provider of Medical Care, the employer, insurance carrier (or third-party administrator) shall pay the bill within 30 days from the filing of the proposed decision or Notice of Decision unless the employer or insurance carrier (or third-party administrator) timely submitted a valuation objection simultaneously with its legal objection(s) to the medical provider's bill.

(3) If the employer or insurance carrier (or third-party administrator) files an application for review pursuant to Workers' Compensation Law section 23 from the Notice of Decision finding legal liability and/or Medical Treatment Guidelines objection in favor of the physician, podiatrist, chiropractor, psychologist, occupational or physical therapist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital or other provider of Medical Care, the employer or insurance carrier (or third-party administrator) may withhold payment of the bills up to the amount in dispute until a Workers' Compensation Law Judge or conciliation decision, or if appealed, a Board Panel decision is rendered by the Board. If a Workers' Compensation Law Judge or conciliation decision, or if appealed, a Board Panel decision is filed finding legal liability and/or Medical Treatment Guidelines objection in favor of the physician, podiatrist, chiropractor, psychologist, occupational or physical therapist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital or other provider of Medical Care, the employer or insurance carrier (or third-party administrator) shall pay the bill within 30 days from the filing of the Workers' Compensation Law Judge or conciliation decision, or if appealed, Board Panel decision unless the employer or insurance carrier (or third-party administrator) timely submitted a valuation objection simultaneously with its legal objection(s) to the medical provider's bill . A subsequent application to the Full Board, except for review by the Full Board of a Board Panel decision which one member dissented from, or to the Appellate Division of the Supreme Court, Third Department, or to the Court of Appeals on the issue of legal liability/or Medical Treatment Guidelines objection shall not operate as a stay of the payment of the bills for medical or hospital services.

(g) Effective date. This regulation shall be effective on January 1, 2020.

N.Y. Comp. Codes R. & Regs. Tit. 12 §§ 325-1.25

Amended New York State Register January 29, 2020/Volume XLII, Issue 04, eff. 1/29/2020

Amended New York State Register October 27, 2021/Volume XLIII, Issue 43, eff. 11/1/2021