New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter C - Medical Treatment and Care › Part 325 - Medical And Surgical Care And Treatment › Subpart 325-1 - General › Section 325-1.4 - Authorization for special services

Current through Register Vol. 46, No. 28, July 10, 2024
(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).