reglab/statecodes huggingface dataset:
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter L - Safety Incentive Program › Part 431 - Safety Incentive Program › Section 431.2 - Eligibility

Current through Register Vol. 46, No. 28, July 10, 2024
This rule shall apply to employers who are eligible for
					 either a premium credit in accordance with subdivision (6) or a reduction in
					 their required security deposit in accordance with subdivision (7) of section 134  of the Workers' Compensation Law and to safety and loss management
					 specialists certified pursuant to Part 60 of this Title who develop and
					 recommend safety incentive plans.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter L - Safety Incentive Program › Part 431 - Safety Incentive Program › Section 431.3 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
For purposes of this Part, the following terms shall
					 mean:
(a) Commissioner. The
				  Commissioner of Labor or his/her designee.
(b) Specialist. An individual, other than a
				  Department of Labor employee assigned to conduct workplace safety and loss
				  prevention consultations pursuant to Subpart 59-1 of this Title, who possesses
				  the qualifications enumerated in section
				  59-1.12(b)(1)-(6) 
				  and in (c) of this Title and who is certified as a safety and loss management
				  specialist by the safety panel pursuant to Part 60 of this Title.
(c) Assignee. A State government department,
				  agency, division or commission which has entered into a agreement or
				  arrangement with the safety panel to process applications filed by individuals
				  who request to be certified, by the safety panel, as specialists.
(d) Board. The Workers' Compensation Board
				  which shall monitor all safety incentive plans and insure that employee
				  representatives are involved in the development of such plans through meetings
				  and discussions with the respective certified safety and loss management
				  specialist pursuant to subdivision (9) of section 134  of the Workers'
				  Compensation Law.
(e) Safety
				  incentive program and safety incentive plan. The safety incentive program and
				  the safety incentive plan, respectively, created pursuant to subdivisions (6)
				  through (10) of section 134  of the Workers' Compensation Law.
(f) Safety panel. The safety panel,
				  established pursuant to subdivision (8) of section 134  of the Workers'
				  Compensation Law, which has the responsibility to:
(1) receive and review applications for
				  certification as safety and loss management specialists; and
(2) certify persons as safety and loss
				  management specialists; and
(3)
				  revoke certification of safety and loss management specialists for just
				  cause.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter L - Safety Incentive Program › Part 431 - Safety Incentive Program › Section 431.4 - Safety incentive plans

Current through Register Vol. 46, No. 28, July 10, 2024
(a) An employer
				  who elects to participate in the safety incentive plan for purposes of
				  obtaining a premium credit in accordance with subdivision (6) or a reduction in
				  security deposit in accordance with subdivision (7) of section 134  of the
				  Workers' Compensation Law shall, within 10 days after completing arrangements
				  with a certified safety specialist to prepare and recommend a safety incentive
				  plan, submit the following to the board:
(1)
				  the name and address of the employer and the employer's insurer, if such
				  employer is not a self-insured employer, and the employer's Federal tax
				  identification number;
(2) evidence
				  demonstrating that the employer satisfies the statutory eligibility
				  requirements for safety incentive program participation, namely:
(i) written documentation that the employer
				  pays at least $5,000 in annual workers' compensation premiums;
(ii) written documentation that the
				  employer's experience rating for the year preceding and the years in which the
				  credit is applied for is less than 1.30 or that the employer is/was
				  self-insured under the Worker's Compensation Law such year(s); and
(iii) a statement, signed by an officer of
				  the employer, that the employer is not subject to the compulsory workplace
				  safety and loss prevention program established in subdivision (1) of section 134  of the Workers' Compensation Law;
(3) the name, address and certification
				  number of the certified specialist(s) preparing and recommending the safety
				  incentive plan;
(4) the date on
				  which such plan preparation is scheduled to begin;
(5) the name(s) of the employee
				  representative(s) who have continuing involvement in the development of the
				  employer's safety incentive plan and a description of the nature of such
				  involvement, including meetings and discussions with the certified safety and
				  loss management specialist.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter L - Safety Incentive Program › Part 431 - Safety Incentive Program › Section 431.5 - Monitoring of safety incentive plans implemented by employers

Current through Register Vol. 46, No. 28, July 10, 2024
(a) At six and
				  twelve months following the submission of the safety incentive plan, or as
				  otherwise required by the board, the employer's certified safety specialist
				  must submit to the employer's insurer and to the board a certification that,
				  based upon regular, documented on-site inspections, the employer is
				  implementing or has implemented the safety incentive plan in accordance with
				  the plan previously submitted to the board in accordance with section
				  431.4  of
				  this Part. The board's designee, as required by the board, and the employer's
				  insurer may also conduct on-site inspection(s) of employers participating in
				  the safety incentive program in order to ensure that the employer has
				  implemented the safety incentive plan in accordance with the plan previously
				  submitted to the board in accordance with section
				  431.4  of
				  this Part.
(b) Failure to submit a
				  safety incentive plan which satisfies the requirements of section
				  431.4  of
				  this Part or failure to undergo on-site inspections and to submit
				  certifications as required by subdivision (a) of this section shall be
				  considered in evaluating whether or not a premium credit shall be granted. For
				  self-insured employers participating in the safety incentive program, such
				  failure shall be considered by the board's office of self-insurance in
				  evaluating whether or not a security deposit reduction shall be
				  granted.
(c) In order to monitor
				  the safety incentive plans implemented by employers as required by subsection
				  (9) of section 134  of the Workers' Compensation Law, the board may request that
				  employers participating in the safety incentive program submit to the board in
				  a prescribed format information including, but not limited to, statistical data
				  on accident rates, workers' compensation costs, and safety program
				  implementation costs.
(d) Any and
				  all information submitted to the board in accordance with this Part may, upon
				  request, be distributed to an insured employer's insurance carrier or to the
				  board's office of self- insurance in order to determine whether or not a
				  premium credit or security deposit reduction shall be granted.
(e) The requirements set forth in this Part
				  do not waive or modify any other State or Federal safety and health standards
				  to which the employer would otherwise be subject, nor does any provision of
				  this rule in any way limit the liability of such employer to fines or other
				  penalties to which it would otherwise be subject for failure to comply with any
				  other State or Federal law or regulation.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter M - Pharmacy And Durable Medical Goods Fee Schedules And Appendices › Part 440 - Pharmacy Fee Schedule › Section 440.1 - Applicability

Current through Register Vol. 46, No. 28, July 10, 2024
This pharmaceutical fee schedule is applicable to
					 prescription drugs or medicines dispensed on or after the most recent effective
					 date of section
					 440.5  of
					 this part for medical care or treatment of an injured employee, regardless of
					 the date of accident or date of disablement. Prescription drugs shall be
					 reimbursed in accordance with the fee schedule as set forth section
					 440.5  in
					 effect on the date the prescription drug is dispensed.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter M - Pharmacy And Durable Medical Goods Fee Schedules And Appendices › Part 440 - Pharmacy Fee Schedule › Section 440.3 - Designated pharmacies

Current through Register Vol. 46, No. 28, July 10, 2024
(a) A
				  self-insured employer or insurance carrier, or its agent, may designate one or
				  more independent pharmacy, pharmacy chain, or pharmacy benefit manager that
				  injured employees must use to obtain outpatient prescription medications,
				  provided that the self-insured employer or insurance carrier:
(1) has filed with the chair, in the manner
				  prescribed by the chair either:
(i) a listing
				  of all pharmacy chains and independent pharmacies it has designated under this
				  section, and notified the chair, in the manner prescribed by the chair, of the
				  addition or removal of any pharmacy chain or independent pharmacy from that
				  listing on a quarterly basis; or
(ii) the name and contact information for a
				  pharmacy benefit manager or other party listed in the notice provided under
				  section
				  440.4(a)(1) 
				  of this Part, provided such pharmacy benefit manager or other party shall
				  provide a list of all pharmacy chains and independent pharmacies it
				  administers, in the manner prescribed by the chair, and notifies the chair, in
				  the manner prescribed by the chair, of the addition or removal of any pharmacy
				  chain or independent pharmacy from that listing on a quarterly basis;
				  and
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter M - Pharmacy And Durable Medical Goods Fee Schedules And Appendices › Part 440 - Pharmacy Fee Schedule › Section 440.4 - Notification

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Universal
				  notice requirements when the self-insured employer or insurance carrier
				  designates an independent pharmacy, pharmacy chain, or pharmacy benefit
				  manager. The self-insured employer or insurance carrier shall provide notice to
				  potential claimants of its designated independent pharmacy, pharmacy chain, or
				  pharmacy benefit manager, in writing and in plain language, as follows:
(1) All insurance carriers that have
				  designated an independent pharmacy or pharmacies, pharmacy chain or chains, or
				  pharmacy benefit manager under this Part shall provide to all employers whose
				  employees will be required to use such pharmacy or pharmacies, a notice not
				  materially different than the form prescribed by the chair for such purpose.
				  All self-insured employers who have designated an independent pharmacy or
				  pharmacies, pharmacy chain or chains, or pharmacy benefit manager under this
				  Part, which their employees are required to use, shall prepare a notice
				  materially the same as the form prescribed by the chair as described in this
				  paragraph. Such notice shall include:
(i)
				  either the identity of all independent pharmacies and pharmacy chains
				  designated by the carrier, or where the carrier designates a pharmacy benefits
				  manager or other party, the identity and contact information for the pharmacy
				  benefits manager or other party, who shall provide a list of all pharmacies in
				  the employee's state to the employee in writing or electronically upon and in
				  accordance with an employee's request; and
(ii) a toll-free number and website where the
				  employee may access information regarding the procedures the employee must
				  follow to fill and refill prescriptions through a remote pharmacy or other
				  means, and may obtain a list of such pharmacies including their name, address
				  and phone number, searchable by geographic location and fully updated as of the
				  date at issue, in that employee's state.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter M - Pharmacy And Durable Medical Goods Fee Schedules And Appendices › Part 440 - Pharmacy Fee Schedule › Section 440.5 - Fee schedule

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
(1)
(i)
				  Prior to October 1, 2019, the maximum reimbursement or payment for prescription
				  drugs or medicines in uncontroverted cases, including all brand name and
				  generic prescription drugs or medicines, shall be the Average Wholesale Price
				  for the national drug code for the prescription drug or medicine on the day it
				  was dispensed minus twelve percent of the Average Wholesale price plus a
				  dispensing fee of four dollars for brand name drugs or medicines, minus twenty
				  percent of the Average Wholesale Price plus a dispensing fee of five dollars
				  for generic drugs or medicines.
(ii) On or after October 1, 2019, the maximum
				  reimbursement or payment for New York Workers' Compensation Formulary drugs or
				  when applicable, drugs that received Prior Authorization in accordance with
				  section 441.4  of this Chapter, including all brand name and generic
				  prescription drugs or medicines, shall be the lesser of the calculated cost,
				  the contract price (for designated pharmacies), or the usual and customary
				  price for the prescription drug or medication.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter M - Pharmacy And Durable Medical Goods Fee Schedules And Appendices › Part 440 - Pharmacy Fee Schedule › Section 440.6 - Prescription drugs or medicines

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
				  When a brand name drug is prescribed to treat an injury for which a
				  self-insured employer or insurance carrier is liable pursuant to Workers'
				  Compensation Law Section 13, a generic drug equivalent, if a generic equivalent
				  is available, shall be provided unless the prescribing physician obtains Prior
				  Authorization pursuant to subdivision (m) of section 441.1.
(b) A billing statement submitted to a
				  self-insured employer or carrier for a prescription drug that has been
				  dispensed shall include the national drug code number of the prescription drug
				  as listed in the national drug code directory maintained by the federal Food
				  and Drug Administration and shall state separately the maximum reimbursement
				  (as set forth in subdivision of section
				  440.5 
				  herein) of the prescription drug and the dispensing fee as
				  applicable.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter M - Pharmacy And Durable Medical Goods Fee Schedules And Appendices › Part 440 - Pharmacy Fee Schedule › Section 440.7 - Transition period

Current through Register Vol. 46, No. 28, July 10, 2024
Where an injured worker has been prescribed a medication or
					 drug prior to receiving the notifications required by section
					 440.4  of
					 this Part, the injured worker may continue to have the prescription refilled at
					 the pharmacy from which it was originally dispensed. Upon receiving written
					 notification under section
					 440.4  of
					 this Part that the self-insured employer or insurance carrier requires an
					 injured worker to obtain all prescription medications from a designated
					 independent pharmacy or pharmacies, chain pharmacy or pharmacies, or from a
					 pharmacy affiliated with a designated pharmacy benefit manager, the injured
					 worker shall transfer any prescriptions for controlled and non-controlled
					 substances or medications to a designated pharmacy at such time as all refills
					 for that prescription are exhausted, or within 90 days following such
					 notification for controlled substances and 60 days following such notification
					 for non-controlled substances, whichever occurs first.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter M - Pharmacy And Durable Medical Goods Fee Schedules And Appendices › Part 440 - Pharmacy Fee Schedule › Section 440.9 - Language other than english

Current through Register Vol. 46, No. 28, July 10, 2024
When the electronic case folder containing a claimant's
					 claim information maintained by the board, which is accessible to the
					 self-insured employer or carrier, indicates that the claimant's primary
					 language is other than English, the notifications required under this Part in
					 regard to the claim shall be in the claimant's primary
					 language.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter M - Pharmacy And Durable Medical Goods Fee Schedules And Appendices › Part 440 - Pharmacy Fee Schedule › Section 440.10 - Compliance

Current through Register Vol. 46, No. 28, July 10, 2024
(a) In order to
				  enforce the provisions of Workers' Compensation Law section 13(i) and13-o and
				  this Part, the chair may exercise his authority under Workers' Compensation Law
				  section 111 to request information, which includes documents, reports,
				  interrogatories and examinations under oath.
(b) The chair may refer any violations of
				  Workers' Compensation Law section 13(i) and13-o or this Part by:
(1) a carrier to the Superintendent of
				  Insurance;
(2) a pharmacy or
				  medical provider other than a physician to the New York State Education
				  Department Office of the Professions; and
(3) a physician to the New York State
				  Department of Health Office for Professional Medical Conduct. In addition to
				  the referral to the referenced above, the chair or his or her designee may also
				  commence a proceeding to revoke or temporarily suspend the authorization of a
				  medical provider.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter M - Pharmacy And Durable Medical Goods Fee Schedules And Appendices › Part 441 - Formulary › Section 441.1 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
(a) "Compound
				  drug" means a drug that is created by combining one or more active
				  pharmaceutical ingredients, and/or one or more inactive ingredients, to meet
				  specific patient medical needs that are not met with U.S. Food and Drug
				  Administration ("FDA")-approved prescription drugs, FDA-approved
				  non-prescription drugs, or other drugs commercially available in the
				  marketplace. For the purposes of this Part, a compound drug shall, at all
				  times, be subject to federal law governing compounding, including title 21,
				  United State Code, sections 353a, 353a-1 and 353b. A compound drug that
				  incorporates a drug identified in Phase A or B of the Formulary or FDA-approved
				  non-prescription drug may only be dispensed for the route of administration
				  (oral, topical or systemic) for which it is FDA-approved. Prior authorization
				  is required for all compound drugs prior to prescription and/or dispensing of
				  such drug.
(b) "Accident or injury"
				  means any accident occurring in the course of employment or any alleged
				  accident that results in personal injury which has caused or will cause a loss
				  of time from regular duties of one day beyond the working day or shift on which
				  the accident or alleged accident occurred, or which has required or will
				  require medical treatment beyond ordinary first aid or more than two treatments
				  by a person rendering first aid; or any disease or alleged disease claimed to
				  have been caused by the nature of the employment and contracted therein. An
				  accident or injury may also be referred to as a Disability event.
(c) "Dispense," "dispensed," or "dispensing"
				  means
(1) the furnishing of a drug upon a
				  medical prescription, or
(2) the
				  furnishing of drugs directly to a patient by a medical provider acting within
				  the scope of his or her practice and pursuant to the dispensing limitations set
				  forth in section 6807 (2)  of the Education
				  Law.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter M - Pharmacy And Durable Medical Goods Fee Schedules And Appendices › Part 441 - Formulary › Section 441.2 - New York Workers' Compensation Formulary

Current through Register Vol. 46, No. 28, July 10, 2024
The New York Workers' Compensation Formulary, sixth edition
					 ( August 31, 2021), incorporated by reference herein, identifies drugs using
					 three lists:
(a) phase A for
				  prescriptions within the first 30 days following an accident or
				  injury;
(b) phase B for
				  prescriptions after, the sooner of, the first 30 days following an accident or
				  injury or acceptance or establishment of the claim; and
(c) perioperative for use during the
				  perioperative period.
Copies of the formulary may be downloaded from the board's
					 website free of charge. The formulary may be examined at the office of the
					 Department of State, 99 Washington Avenue, Albany, New York 12231, the
					 Legislative Library, the libraries of the New York State Supreme Court, and the
					 district offices of the board, or obtained from the Board's website.
					 Information about the formulary can be requested by email at
					 WCBFormularyQuestions@wcb.ny.gov, or by telephone at
					 1-800-7812362.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter M - Pharmacy And Durable Medical Goods Fee Schedules And Appendices › Part 441 - Formulary › Section 441.3 - Applicability, Effective Dates and Notice

Current through Register Vol. 46, No. 28, July 10, 2024
The Formulary shall apply to all prescriptions following an
					 accident or injury regardless of the date of accident or disablement and
					 regardless of where the claimant lives. The Formulary shall be subject to the
					 following:
(a) Effective Dates.
(1) New Prescriptions. Six months from the
				  effective date of this Part, every new prescription shall be prescribed and
				  dispensed consistent with the Formulary and this Part regardless of the date of
				  accident or disablement and subject to any required Prior
				  Authorization.
(2) Refill and
				  Renewal Prescriptions. On or after September 13, 2021, every refill and renewal
				  prescription shall be prescribed and dispensed consistent with the Formulary
				  and this Part regardless of the date of accident or disablement and subject to
				  any required Prior Authorization.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter M - Pharmacy And Durable Medical Goods Fee Schedules And Appendices › Part 441 - Formulary › Section 441.4 - Application of Formulary

Current through Register Vol. 46, No. 28, July 10, 2024
The Formulary identifies drugs using the generic or
					 chemical name. The Formulary organizes these drugs into three lists identified
					 below and includes both prescription and over-the-counter drugs.
					 Over-the-counter Formulary drugs should be billed directly to the carrier or
					 its pharmacy benefits manager.
(a)
				  Phase A: The drugs on this list may be prescribed and dispensed without
				  obtaining Prior Authorization during the thirty days following an accident or
				  injury or until the carrier accepts the claim or the Board establishes the
				  claim, whichever is less, for up to a thirty days supply, subject to the
				  following:
1. Controlled substances and muscle
				  relaxants may not exceed a single seven-day supply of a Formulary drug. These
				  medications are indicated on Phase A of the Formulary as "1" in the "Special
				  Considerations" column.
2.
				  Anti-infectives, including antibiotics and post-exposure medications, may be
				  prescribed and dispensed in accordance with the prescribed course of treatment.
				  These medications are indicated on Phase A of the Formulary as "2" in the
				  "Special Considerations" column.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter M - Pharmacy And Durable Medical Goods Fee Schedules And Appendices › Part 441 - Formulary › Section 441.5 - Prior Authorization Process

Current through Register Vol. 46, No. 28, July 10, 2024
(a) A medical
				  provider must obtain Prior Authorization before prescribing or dispensing:
1. Phase A formulary drugs (including
				  compound drug ingredients) other than as set forth in subdivision (a) of
				  section
				  441.4 
				  herein;
2. Phase B formulary drugs
				  (including compound drug ingredients) other than as set forth in subdivision
				  (b) of section
				  441.4 
				  herein; or
3. Perioperative
				  formulary drugs (including compound drug ingredients) other than as set forth
				  in subdivision (c) of section
				  441.4 
				  herein.
4. Brand name drugs for a
				  generically available formulary drug, including a brand name drug available in
				  a different dosage or strength.
5.
				  Non-Formulary drugs;
6. Compound
				  drugs;
7. Formulary drugs
				  prescribed in a manner not consistent with the adopted Medical Treatment
				  Guidelines when a case has been accepted by the carrier or established by the
				  Board.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter M - Pharmacy And Durable Medical Goods Fee Schedules And Appendices › Part 441 - Formulary › Section 441.6 - Review by the Board of a Prior Authorization Denial

Current through Register Vol. 46, No. 28, July 10, 2024
(a) If the
				  Carrier's Physician issues a denial or a partial approval, the medical provider
				  may seek review by the Board's Medical Director's Office. The medical provider
				  may not seek review by the Board's Medical Director's Office unless the medical
				  provider has received a denial or partial approval by the Carriers'
				  Physician.
(b) All requests for
				  review of denials or partial approvals of a Prior Authorization request shall
				  be submitted to the Medical Director's Office in the format prescribed by the
				  Chair. The Chair or Medical Director may designate private entities to evaluate
				  such requests for review of denials by a Carrier's Physician provided that the
				  entity has:
1. the appropriate URAC
				  accreditation or such accreditation/certification as designated by the
				  Chair,
2. other demonstrated
				  expertise and criteria established by the Board; and
3. no conflict of interest exists in
				  resolving the subject dispute.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter M - Pharmacy And Durable Medical Goods Fee Schedules And Appendices › Part 441 - Formulary › Section 441.7 - Changes to the Formulary

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The
				  Formulary shall be updated, not less than annually, to account for changes to
				  medications available on the market.
(b) The Medical Director and/or Chair, or his
				  or her designees, shall review any drugs recommended for addition or removal
				  from the Formulary, and assess requests regarding drugs included and/or
				  excluded from the Formulary. Written documentation of the review and assessment
				  of changes to the Formulary shall be maintained by the Board and posted on the
				  Board's website. Decisions regarding changes to the Formulary shall be binding
				  and not appealable under Workers' Compensation Law section 23.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter M - Pharmacy And Durable Medical Goods Fee Schedules And Appendices › Part 441 - Formulary › Section 441.8 - Medical Treatment Guidelines and Formulary

Current through Register Vol. 46, No. 28, July 10, 2024
In the event that a conflict exists between the Board's
					 medical treatment guidelines and the New York Formulary, the provisions of the
					 medical treatment guidelines shall prevail, unless the drug was prescribed in
					 accordance with Phase A or Phase B of the Formulary.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter M - Pharmacy And Durable Medical Goods Fee Schedules And Appendices › Part 442 - Durable Medical Goods Fee Schedule › Section 442.1 - Applicability

Current through Register Vol. 46, No. 28, July 10, 2024
(a) This durable
				  medical equipment fee schedule is applicable to durable medical equipment,
				  medical/surgical supplies and other such items prescribed in the course of
				  medical care or treatment for an injured employee dispensed on or after the
				  most recent effective date of section
				  442.2  of
				  this Part, regardless of the date of accident or date of disablement for an
				  occupational disease. Durable medical equipment, medical/surgical supplies and
				  other such items dispensed on or after July 11, 2007, but prior to the most
				  recent effective date of section
				  442.2  of
				  this part, shall be reimbursed pursuant to the fee schedule in section
				  442.2  of
				  this part in effect on the date the durable medical equipment, medical/surgical
				  supply or other such time was dispensed.
(b) The Official New York Workers'
				  Compensation Durable Medical Equipment Fee Schedule, as set forth in section
				  442.2  of
				  this Title, shall be updated on an annual basis. New items of durable medical
				  equipment added during the previous year will not have a fee associated to that
				  item. Prior authorization to dispense such durable medical equipment as well as
				  the price paid for the item will be required in accordance with section 442.4 
				  of this Title before such durable medical equipment may be supplied to the
				  claimant.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter M - Pharmacy And Durable Medical Goods Fee Schedules And Appendices › Part 442 - Durable Medical Goods Fee Schedule › Section 442.2 - Fee schedule

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
(1) The maximum permissible charge for the
				  purchase of durable medical equipment, medical/surgical supplies, and orthotic
				  and prosthetic appliances shall be the fee payable for such equipment or
				  supplies under the Official New York Workers' Compensation Durable Medical
				  Equipment Fee Schedule, fourth edition, December 2023, prepared and published
				  by the Board, which is hereby incorporated by reference, available for viewing
				  free of charge on the Board's website.
(2) The maximum permissible monthly charge
				  for the rental of durable medical equipment shall be the rental price listed in
				  the Official New York Workers' Compensation Durable Medical Equipment Fee
				  Schedule multiplied by the total number of months or weeks respectively for
				  which the durable medical equipment is needed. In the event the total rental
				  charge exceeds the purchase price, the maximum permissible charge for the
				  durable medical equipment shall be the purchase price listed in the Official
				  New York Workers' Compensation Durable Medical Equipment Fee Schedule, whether
				  or not the claimant keeps the durable medical equipment or returns it when no
				  longer needed.
(3) Within six
				  months of the effective date of this section, all durable medical equipment and
				  supplies shall be provided (a) by a New York State Medicaid Enrolled Supplier
				  and (b) in accordance with the Ground Rules therefore as set forth in the
				  Official New York Workers' Compensation Durable Medical Equipment Fee Schedule,
				  except for durable medical equipment provided as part of medical treatment
				  provided in conformity with the Ground Rules of the Official New York Workers'
				  Compensation Medical Fee Schedule. A supplier's MMIS ID number must be
				  submitted with every bill for durable medical equipment. The Official New York
				  State Workers' Compensation Durable Medical Equipment Fee Schedule for durable
				  medical equipment, medical/surgical supplies, and orthotic and prosthetic
				  appliances incorporated by reference herein is available on the Board's website
				  at wcb.ny.gov.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter M - Pharmacy And Durable Medical Goods Fee Schedules And Appendices › Part 442 - Durable Medical Goods Fee Schedule › Section 442.3 - Payment of bills

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Bills for
				  durable medical equipment, medical/surgical supply, or orthotic or prosthetic
				  appliance shall be paid in accordance with the fee schedule established by
				  section
				  442.2  of
				  this Part and section 13-g  of the Workers' Compensation Law. Objections to and
				  resolution of billing disputes shall be in the format and according to the
				  process prescribed by the Chair and as set forth in section 13-g  of the
				  Workers' Compensation Law and section
				  325-1.25 
				  of Part 325 of this Chapter.
Effective date. This regulation shall be effective on
					 January 1, 2020.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter M - Pharmacy And Durable Medical Goods Fee Schedules And Appendices › Part 442 - Durable Medical Goods Fee Schedule › Section 442.4 - Prior Authorization Process for Durable Medical Equipment

Current through Register Vol. 46, No. 28, July 10, 2024
(a) When identified
				  as requiring Prior Authorization in the Official New York State Durable Medical
				  Equipment Fee Schedule incorporated by reference in section
				  442.2 
				  herein, a medical provider must obtain Prior Authorization for the durable
				  medical equipment.
1. For purposes of this
				  section and section 442.5  herein, medical provider shall mean a physician,
				  nurse practitioner, physician assistant, podiatrist, chiropractor, dentist,
				  optometrist and audiologist.
2. The
				  medical provider must obtain prior authorization before such durable medical
				  equipment may be supplied to the claimant.
3. In the event of a medical emergency,
				  requiring immediate use of durable medical equipment following an accident or
				  injury, exacerbation of an earlier accident or injury or unanticipated results
				  following surgery:
i. Such durable medical
				  equipment may be dispensed without prior authorization.
ii. The medical provider shall submit the
				  bill for the durable medical equipment together with a description of the
				  emergency and justification of the need for the durable medical equipment
				  together with submission of the CMS-1500.
iii. The carrier, self-insured employer or
				  third-party administrator may deny payment for the durable medical equipment on
				  the basis of medical necessity.
iv.
				  Inappropriate identification of a need for emergency durable medical equipment
				  by a medical provider, or inappropriate denial by a carrier, self-insured
				  employer of third-party administrator, may result in imposition of penalties by
				  the Board.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter M - Pharmacy And Durable Medical Goods Fee Schedules And Appendices › Part 442 - Durable Medical Goods Fee Schedule › Section 442.5 - Review by the Board of a Prior Authorization Denial

Current through Register Vol. 46, No. 28, July 10, 2024
(a) If the Carrier's Physician issues a
				  denial or a partial approval, the medical provider may seek review by the
				  Board's Medical Director's Office. The medical provider may not seek review by
				  the Board's Medical Director's Office unless the medical provider has received
				  a denial or partial approval by the Carrier's Physician.
(b) All requests for review of denials or
				  partial approvals of a Prior Authorization request shall be submitted to the
				  Medical Director's Office in the format prescribed by the Chair. The Chair or
				  Medical Director may designate private entities to evaluate such requests for
				  review of denials by a Carrier's Physician provided that the entity has:
1. the appropriate URAC accreditation or such
				  accreditation/certification as designated by the Chair,
2. other demonstrated expertise and criteria
				  established by the Board; and
3. no
				  conflict of interest exists in resolving the subject dispute.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter M - Pharmacy And Durable Medical Goods Fee Schedules And Appendices › Part 444 - Dental Fee Schedule › Section 444.1 - Applicability

Current through Register Vol. 46, No. 28, July 10, 2024
This dental fee schedule is applicable to dental treatment
					 and procedures performed on or after, March 1, 2009, for the necessary care and
					 treatment of an injured employee regardless of the date of accident or date of
					 disablement. The date of service for dental treatment or for a dental procedure
					 shall be the applicable date for reimbursement in accordance with this fee
					 schedule. Dental treatment or procedures performed prior to March 1, 2009,
					 shall be reimbursed at the usual and customary rate in the location where the
					 claimant resides.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter M - Pharmacy And Durable Medical Goods Fee Schedules And Appendices › Part 444 - Dental Fee Schedule › Section 444.2 - Fee schedule

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The
				  dental fee schedule for all dental services shall be the Official New York
				  Workers' Compensation Dental Fee Schedule, First Edition, March 1, 2009,
				  prepared by the chair and published by the board, which is hereby incorporated
				  by reference, except that the maximum reimbursement for dental services in
				  cases in which the insurance carrier files or has filed a notice of controversy
				  pursuant to Workers' Compensation Law, section 25(2)(a) or (b) shall be 25
				  percent more than the fees set forth in the Official New York Workers'
				  Compensation Dental Fee Schedule.
(b) The Official New York Workers'
				  Compensation Dental Fee Schedule incorporated by reference herein may be
				  examined at the office of the Department of State, 99 Washington Avenue, Suite
				  650, Albany, NY 12231, the Legislative Library, the libraries of the New York
				  State Supreme Court, and the district offices of the board in Albany,
				  Binghamton, Brooklyn, Buffalo, Hauppauge, Hempstead, Manhattan, Peekskill,
				  Queens, Rochester and Syracuse. Copies may be obtained from the board by
				  writing to New York Workers' Compensation Dental Fee Schedule, Bureau of Health
				  Management, New York State Workers' Compensation Board, 100 Broadway-Menands,
				  Albany, NY 12241 or by telephone at 1-800-781-2362 or by email at
				  general_information@wcb.state.ny.us
(c) The dental fee schedule shall be updated
				  by the chair as he or she deems warranted by changes in market rates. The
				  dental fee schedule consists of a list of current dental terminology (CDT)
				  codes and descriptions of treatment services and procedures as published by the
				  American Dental Association with a corresponding maximum fee to be charged by
				  dental providers. Nothing shall prohibit a provider from charging a fee that is
				  less than the fee schedule.
(d) Any
				  treatment or procedure provided in connection with a work related injury not
				  specifically contained in the dental fee schedule should be billed using CDT
				  Code D9999 "Unspecified Adjunctive Procedure By Report" (BR). The provider
				  should establish a fee consistent in relativity with the other fees listed in
				  the dental fee schedule. Any bill submitted by a dental provider which lists
				  CDT Code D9999 shall be accompanied by a report providing the reasons why such
				  procedure is necessary to treat the injured employee.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter M - Pharmacy And Durable Medical Goods Fee Schedules And Appendices › Part 444 - Dental Fee Schedule › Section 444.3 - Payment of bills and reimbursement requests

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Bills submitted by a dental provider to
				  the carrier or self-insured employer for payment or reimbursement shall be paid
				  according to the fee schedule adopted under Workers' Compensation Law, section
				  13(a) within 45 calendar days of receipt of the bill or reimbursement
				  request.
(b) Where the liability of
				  the self-insured employer or carrier for the claim has not been established or
				  the treatment or procedure is not for a causally related condition, the
				  self-insured employer or carrier shall pay any undisputed amount of the bill or
				  reimbursement request and notify the board, claimant and dental provider in
				  writing using the form prescribed by the chair for this purpose within 45
				  calendar days of receipt of the claim or reimbursement request:
(1) that the claim is not being paid and the
				  reason for non-payment of the claim; or
(2) to request additional information needed
				  to reasonably determine the self-insured employer's or carrier's liability for
				  the claim or whether the dental treatment or procedure is causally related to
				  the injury.
Upon receipt of the information reasonably requested, the
					 self-insured employer or carrier shall have 30 days to pay the bill or
					 reimbursement request or provide written notice to the board, claimant and
					 dental provider using the form prescribed by the chair for this purpose
					 explaining why the bill is not being paid with copies of the additional
					 information requested attached to the form to support the determination.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter VI - State Insurance Fund › Part 450 - Conduct Of The State Insurance Fund › Section 450.1 - Insurance policies

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
				Insurance policies for workers' compensation and employer's liability,
				disability benefits, volunteer ambulance and volunteer firefighters' benefits
				shall be issued in the name of the State Insurance Fund pursuant to authority
				vested in it by the Workers' Compensation Law, the Disability Benefits Law, the
				Volunteer Ambulance Workers' Law and the Volunteer Firefighters' Benefit Law.
				Such policies shall be signed by the executive director, the director of
				underwriting or such other officer as may be designated by the commissioners
				for such purpose. The respective policies shall contain such terms and
				conditions, consistent with the applicable laws as will insure protection to
				the employer under the respective provisions of said laws and will assure to
				the persons entitled thereto the compensation or benefits under the respective
				provisions of said laws. The provisions of the Workers' Compensation Law, the
				Disability Benefits Law, the Volunteer Ambulance Workers' Law or the Volunteer
				Firefighters' Benefit Law, whichever is applicable, shall control as to the
				meaning or interpretation of any provisions of the insurance policy as to which
				doubt may exist. The policies for workers' compensation insurance may also
				provide for assuring to persons entitled thereto the compensation or benefits
				provided for in any Federal Compensation Act as to injuries sustained by
				employees of an employer insured with the State Fund provided such employer's
				liability is incident to an employment carried on in New York State.
(b) Coverage under all policies shall be
				effective as of 12:01 a.m. on the day following the acceptance and approval of
				the application for insurance. No coverage shall be effective until receipt of
				payment of the required deposit premium, and such coverage shall be evidenced
				by the issuance of a binder or policy of insurance, and such contracts shall
				specify the period for which insurance is afforded, and the location or
				locations of the business or operations of the employer insured thereunder, and
				may provide for such inclusions and exclusions as are permitted by
				law.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter VI - State Insurance Fund › Part 450 - Conduct Of The State Insurance Fund › Section 450.2 - Premium rates

Current through Register Vol. 46, No. 28, July 10, 2024
The rates for workers' compensation and employer's liability,
				  disability benefits, volunteer ambulance and volunteer firefighters' benefit
				  insurance shall be fixed as low as possible consistent with the maintenance of
				  a solvent fund and reasonable reserves and surplus. For such purpose the rate
				  manual and rating plans and classifications established and promulgated by the
				  Compensation Insurance Rating Board and approved by the Superintendent of
				  Insurance pursuant to, and under the authority of the Insurance Law, are hereby
				  adopted insofar as they are consistent with article 6 of the Workers'
				  Compensation Law. Such rate manual and rating plans as applied to the standard
				  risks insured with the State Fund may be modified to permit the application of
				  such initial discount in rates and to permit other reductions in net costs of
				  insurance as, in the judgment of the commissioners, or under their direction,
				  seem to be appropriate consistent with the financial status of the State Fund;
				  and similarly, for nonstandard risks, such rate manual and rating plans may be
				  modified to permit the application of increased rates as may reflect the
				  peculiar hazards of each individual risk. The term standard risk shall refer to
				  a risk whose indicated accident and moral hazards approximate the normal
				  hazards of the risk's governing classification. Rates for disability benefits
				  shall be fixed as low as possible in accordance with the Insurance
				  Law.
New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter VI - State Insurance Fund › Part 450 - Conduct Of The State Insurance Fund › Section 450.3 - Payroll records and audits

Current through Register Vol. 46, No. 28, July 10, 2024
Audits of the payroll records of the risks insured with the
				  State Insurance Fund shall be made at such times as is provided by the terms of
				  the insurance policy and as often as may be necessary for the purposes of the
				  State Fund and statements from assureds of the number of employees and the
				  amount of payroll in the business insured may be required as
				  needed.