Current through Register Vol. 46, No. 12, March 20, 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).
(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.