N.Y. Comp. Codes R. & Regs. Tit. 12 §§ 325-1.4

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

Section 325-1.4 - Authorization for special services

(a) Authorization for medical care in accepted or established claims.

(1) When it is necessary for the attending provider to provide or prescribe medical care or supplies costing more than $1,000, he or she must request and secure authorization from the insurance carrier, self-insured employer or third-party administrator, by setting forth the medical necessity of the special services required in the electronic format prescribed by the Chair. Such requests are not required in an emergency or for pre-authorized procedures as set forth in subdivision (d) of this section and section 324.2(d) of this Title.

(2)

(i) This section also applies to hospitals, specialists, consultants and surgeons, who are actually engaged to perform such services.

(ii) For the services of a physician assistant, the supervising physician shall make the request for authorization for special services.

(3) The treating provider seeking authorization shall inform the claimant of the request for prior authorization (PAR: Non-MTG Over $1,000) (hereinafter "PAR") and submit the PAR in the manner prescribed by the Chair, which may be electronic. The treating provider shall not submit a PAR for the same special service multiple times without any change of the claimant's medical condition.

(4) Insurance carriers, self-insured employer or 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 PAR review. Such contact information may include the contacts' direct telephone number(s) and email address(es).

i. 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.

ii. 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.

iii. In the event that a carrier, self-insured employer or third-party administrator fails to 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 carrier, self-insured employer or third-party administrator may be subject to:

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

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

(5) In response to a PAR related to an established or accepted body part or illness, the insurance carrier, self-insured employer or third-party administrator may have the claimant examined within four business days if the claimant is hospitalized or 30 days if patient is not hospitalized, by an appropriate specialist who is authorized by the Chair, to conduct independent medical examinations of workers' compensation claimants. 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 30 calendar 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.

(i) If such specialist is not available or where the claimant resides outside of state, consultation may be rendered by a qualified provider who may conduct the independent medical examination as provided in Workers' Compensation Law section 137 (3) (a) and section 300.2(b)(9) and (d)(7) of this Title.

(ii) 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, the carrier, self-insured employer or third-party administrator may deny the prior authorization request within 15 days without an independent medical examination; however, nothing herein shall prohibit a carrier, self-insured employer or third-party administrator from obtaining an opinion from an independent medical examiner. When a PAR is denied without an IME, 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.

(6) The insurance carrier, self-insured employer or third-party administrator shall respond to the PAR in the format prescribed by the Chair within 30 days.

** If the PAR has been denied, the insurance carrier, self-insured employer or third-party administrator shall submit with the written response a report offering a conflicting opinion from an independent medical examiner, a qualified medical professional as defined in section 300.2(b)(9) of this Title, or, if the report was made upon review of the records without a physical examination, a physician authorized to treat workers' compensation claimants. If the report offering a conflicting opinion is already contained in the Board file, the insurance carrier, self-insured employer or third-party administrator shall not submit the report but shall identify the report on the form prescribed by the Chair by providing the name of the independent medical examiner, qualified medical professional as defined in section 300.2(b)(9) of this Title, or physician authorized to treat workers' compensation claimants who gave the conflicting opinion, the date of the report, and the date it was received by the Board. Nothing herein shall relieve the carrier, self-insured employer or third-party administrator from complying with the provisions of section 300.23 of this Title. 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

(7) If such authorization or denial is not submitted to the treating provider within 30 calendar days, such request may be deemed authorized and the insurance carrier, self-insured employer or third-party administrator shall be liable for payment for such special service. The Chair may issue an order stating that such request is deemed authorized or requiring the carrier, self-insured employer or third-party administrator to provide written authorization, if such documentation is required by the claimant to secure necessary medical treatment and 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. Such order of the Chair is not appealable under Workers' Compensation Law section 23.

(8)

(i) Upon the timely receipt of a denial of a PAR and a report offering a conflicting opinion from an independent medical examiner, a qualified medical professional as defined in section 300.2(b)(9) of this Title, or, if the report was made upon review of the records without a physical examination, a physician authorized to treat workers' compensation claimants, the Board shall order the claim into the Expedited Hearing Process wherein an expedited hearing shall be scheduled within 30 days. Notice of the expedited hearing shall provide that the parties may depose the claimant's treating provider and the independent medical examiner, qualified medical professional, or physician authorized to treat workers' compensation claimants who submitted the conflicting medical report at or prior to the hearing. If the physicians are deposed, transcripts shall be provided to the Board on or before the hearing. If the claimant is unrepresented the testimony of claimant's treating provider and the independent medical examiner shall be taken at a hearing. For good cause shown, the Workers' Compensation Law Judge may grant an adjournment if one or both of the medical professionals cannot be deposed and transcripts prior to the Board at or prior to the hearing, or if one or both of the medical professionals cannot appear to testify at the expedited hearing. The Workers' Compensation Law Judge shall rule on the PAR at the expedited hearing and file a subsequent decision, or shall issue a reserved decision on the issue within 15 days of the expedited hearing date. The case shall not be continued for further development of the record except where there are complex medical issues of diagnosis or causation present and then it shall be continued for no more than 30 days.

(ii) If the form prescribed by the Chair denying the PAR is untimely or does not reference or have attached a conflicting medical report from an independent medical examiner, a qualified medical professional as defined in section 300.2(b)(9) of this Title, or, if the report was made upon review of the records without a physical examination, a physician authorized to treat workers' compensation claimants, the Chair will issue an order stating that such PAR is deemed authorized. Such order of the Chair is not appealable under Workers' Compensation Law section 23.

(9) Pursuant to Workers' Compensation Law section 13-a (4)(b), claimants shall cooperate in an examination by the insurance carrier, self-insured employer or third-party administrator's independent medical examiner. If a claimant fails to attend an examination scheduled in accordance with Workers' Compensation Law section 137 and section 300.2 of this Title at a medical facility convenient to the claimant during the 30 day authorization time period, the insurance carrier, self-insured employer or third-party administrator may file the form prescribed by the Chair along with contemporaneous supporting evidence that claimant failed to attend a scheduled medical examination pursuant to the provisions of Workers' Compensation Law section 137. Upon receipt of the form prescribed by the Chair for this purpose and the contemporaneous supporting evidence of failure to attend the scheduled medical examination, the Board shall order the claim into the Expedited Hearing Process wherein an expedited hearing shall be scheduled within 30 days on the request for prior authorization and the claimant's failure to attend the independent medical examination.

(10) Such authorization is not required in an emergency under the provisions of Workers' Compensation Law section 13-a (5).

(b) Authorization for medical care when the right to compensation is controverted or the body part or condition has not been established.

(1) When it is necessary for the treating provider to secure specialist consultations, surgical operations, physiotherapeutic or occupational therapy procedures, x-ray examinations or special diagnostic laboratory tests costing more than $1,000, or when it is necessary for a physical or occupational therapist to continue physiotherapeutic or occupational therapy procedures prescribed by a treating provider costing more than $1,000, and the claim is controverted or the time to controvert the claim has not expired or the body part or condition has not been established, the treating provider shall submit a PAR to the insurance carrier, self-insured employer or third-party administrator who would become responsible in the event the claim is adjudicated compensable by following the procedures in subdivision (a) of this section. All such procedures are applicable to such requests.

(2) The authorization herein referred to, if granted by the insurance carrier, self-insured employer or third-party administrator, is limited to the question only of medical necessity of the services requested, and such authorization shall not be construed as an admission that the condition for which these services are required is compensable.

(3) When the Chair issues an order, pursuant to paragraph (a)(7) of this section in a controverted case, the carrier, self-insured employer or third-party administrator shall not be responsible for the payment of such services until the question of compensability is resolved and then only if the claim is established as compensable.

(c) Multiple special services. If a treating provider provides medical treatment or special services to more than one body part or more than one medical treatment or special service to the same body part, such treatment or special services shall be considered separate and shall not require a PAR pursuant to Workers' Compensation Law section 13-a (5) or this section if the medical treatments or special services individually costs less than $1,000. Notwithstanding the previous sentence, if the medical treatment or special services are a series of related treatment or care, such as physical or occupational therapy, or part of a battery of related tests, such as electrodiagnostic tests, the aggregate amount of such treatment, care, or tests shall be considered as a single request and shall require a PAR pursuant to Workers' Compensation Law section 13-a (5) or this section if the aggregate amount is more than $1,000.

N.Y. Comp. Codes R. & Regs. Tit. 12 §§ 325-1.4

Amended New York State Register September 11, 2019/Volume XLI, Issue 37, eff. 9/11/2019

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