New York Codes, Rules and Regulations
Title 12 - DEPARTMENT OF LABOR
Chapter V - Workers' Compensation
Subchapter C - Medical Treatment and Care
Part 324 - Medical Treatment Guidelines
Section 324.4 - PARs confirming consistency with MTG or medical necessity when no MTG
Current through Register Vol. 46, No. 12, March 20, 2024
(a) Every insurance carrier, self-insured employer and third-party administrator shall designate a qualified employee or employees as a point of contact for the Board and Treating Medical Providers regarding PARs to confirm consistency with the Medical Treatment Guidelines or medical necessity. Insurance carriers, self-insured employers and 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 PARs to confirm consistency with the Medical Treatment Guidelines (PAR: MTG Confirmation) or review for medical necessity (PAR: Non-MTG $1,000 or Under).
Such contact information may include the contacts' direct telephone number(s) and email address(es).
(b) Submission by Medical provider
(c) The insurance carrier, self-insured employer or third-party administrator has eight business days from submission of the PAR to confirm consistency with the Medical Treatment Guidelines or medical necessity, and to approve or deny the medical care. 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. 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 8 business 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.
Unless the PAR is made in a case that has been closed, disallowed or cancelled, where ongoing medical treatment is resolved by an agreement pursuant to section 32 of the Workers' Compensation Law, or controverted in accordance with section 300.22(b)(1)(ii) or (c)(1) of this Chapter, any PAR must be reviewed by the insurance carrier, self-insured employer or third-party administrator Carrier's Physician before it may be denied or partially approved. When an insurance carrier, self-insured employer, or third-party administrator denies or partially approves a PAR, the insurance carrier, self-insured employer, or third-party administrator must also assert any other basis for denial or such basis for denial will be deemed waived. Except as set forth in subparagraph (2) below, all denials or partial approvals must be made by the Carrier's Physician. A partial approval limits the length of time or frequency of the treatment, or authorizes a related but different treatment than that requested in the PAR.
(d) If a claim is controverted or the time to controvert the claim has not expired, and the insurance carrier, self-insured employer or third-party administrator agrees that the medical care for which a PAR is requested is consistent with the Medical Treatment Guidelines or is medically necessary, such agreement shall not be construed as an admission that the condition for which the PAR is requested is compensable and the insurance carrier, self-insured employer or third-party administrator is not liable for the cost of such treatment unless the claim or condition is established.
(e) For requests made pursuant to (b)(1) herein, if the insurance carrier, self-insured employer or third-party administrator denies that the medical care for which a PAR is requested is consistent with the Medical Treatment Guidelines, the Treating Medical Provider may elect to submit a PAR (PAR: MTG Variance) in accordance with section 324.3 of this Part or submit a request for review .
The Treating Medical Provider may request review of the denial of the PAR within 10 calendar days of the date of the denial by submission of the request in the format prescribed by the Chair which may be electronic. The Medical Director's Office shall rule on whether the medical care is consistent with the Medical Treatment Guidelines and issue a notice of resolution setting forth the ruling and the basis for such ruling . Such notice of resolution is binding and not appealable under Workers' Compensation Law Section 23.
(f) For requests made pursuant to (b)(2) herein, if the insurance carrier , self-insured employer or third-party administrator denies that the medical care for which prior approval is requested is causally related or medically necessary, the Treating Medical Provider may submit a request for review in the format prescribed by the Chair. Upon the request of the Treating Medical Provider, the PAR and denial will be referred to conciliation for a determination as to whether the medical care is causally related and medically necessary. Conciliation shall issue a proposed conciliation decision setting forth the ruling and the basis for such ruling. The claimant and insurance carrier, self-insured employer or third-party administrator may object to the proposed conciliation decision within thirty calendar days in accordance with part 312 of this Chapter. The Treating Medical Provider may not object to the proposed conciliation decision.
(g) An insurance carrier, self-insured employer or third-party administrator may not dispute a bill for medical care on the basis that it was not consistent with the Medical Treatment Guidelines or that it was not causally related or medically necessary, if it has approved a request for prior approval for such medical care or the Board has issued a decision approving the treatment or an Order of the Chair.
(h) An insurance carrier, self-insured employer, or third-party administrator may not object to or deny payment of a medical bill solely because the treating medical provider did not submit a PAR under this section prior to rendering treatment. Denial of a medical bill solely for this reason may result in a penalty pursuant to sections 13-a(6) and 114-a(3).