New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter V - Medical Facilities › Subchapter C - State Hospital Code › Article 4 - Managed Care › Part 732 - Workers' Compensation Preferred Provider Organizations › Subpart 732-1 - Provider Certification › Section 732-1.1 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
The following terms, as used in this Part, shall have
						  the following meanings:
(a) Carrier or
						insurer shall mean the insuring, risk bearing entity which contracts with the
						employer and the PPO for the provision of workers' compensation medical and
						service benefits.
(b) Chair shall
						mean the Chair of the Workers' Compensation Board.
(c) Claimant shall mean an individual
						employed by or otherwise covered for workers' compensation benefits by a
						participating employer and eligible for medical care provided by a PPO who
						receives treatment for or applies for medical and/or health services for any
						accidental injury arising out of and in the course of employment or for
						occupational disease.
(d)
						Commissioner shall mean the Commissioner of Health.
(e) Emergency or urgent care shall mean
						medical care, treatment, services, products or accommodations provided to an
						injured or ill employee for a sudden onset of a medical condition of such
						nature that failure to render immediate care would reasonably result in
						deterioration of the injured employee's medical condition.
(f) Governing body shall mean the board of
						directors or trustees of a not-for-profit corporation, the officers, directors
						and stockholders of a business corporation, all partners in a partnership or
						the individual proprietor of a PPO.
(g) Preferred Provider Organization or PPO
						shall mean a plan certified pursuant to the requirements of this Subpart owned,
						operated or administered by an entity that provides or arranges for the
						coordination and delivery of all services required by subdivision (h) of this
						section to all persons covered by such plan. No insurer or employer shall have
						any financial interest in the PPO.
(h) Services provided by a PPO shall include
						all services provided or arranged for under the Workers' Compensation Law to
						diagnose, treat and rehabilitate a claimant requiring medical treatment of an
						occupational disease or an accidental injury arising out of and in the course
						of employment, which shall include but not be limited to:
(1) inpatient hospital services;
(2) emergency or urgent care
						services;
(3) primary care
						physician services;
(4) diagnostic
						imaging services;
(5) physical
						therapy, occupational therapy and rehabilitation services;
(6) other therapeutic services;
(7) mental health professional
						services;
(8) pharmacy
						services;
(9) specialist services
						as required by patient conditions and/or authorized under the Workers'
						Compensation Law;
(10) occupational
						disease and injury services; and
(11) such other services as may be required
						by the commissioner to be provided as a condition of certification.