Current through Register Vol. 45, No. 52, December 27, 2023
(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.
(b) When a durable medical equipment is not
listed 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, including a purchase or rental price for such equipment. The
medical provider must obtain prior authorization before such durable medical
equipment may be supplied to the claimant.
(c) When the Chair identifies durable medical
equipment by HCPCS code or purchase/rental price threshold as requiring prior
authorization, such equipment shall require prior authorization before being
supplied to the claimant.
(d) A
medical provider may request prior authorization for any durable medical
equipment listed on the Official New York State Durable Medical Equipment Fee
Schedule. The carrier or self-insured employer may not object to payment for
such durable medical equipment unless it has made a timely denial of the prior
authorization request.
(e) When
responsibility for payment is apportioned between more than one carrier or
self-insured employer, the medical provider shall seek Prior Authorization from
the primary carrier or self-insured employer on the claim (as identified by the
Board). Approval by such carrier or self-insured employer shall be deemed
approval by all responsible carriers or self-insured employers.
(f) Insurance carriers and self-insured
employers 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 Prior Authorization review. Such contact information shall
include the contacts' email address(es).
1. If
the designated point(s) of contact changes at any time for any reason, the
insurance carrier or self-insured employer shall notify the Chair or his or her
designee of such change in the manner prescribed by the Chair.
2. The list of designated points of contact
for each insurance carrier and self-insured employer shall be maintained by the
Board electronically. When a treating medical provider submits a Prior
Authorization request electronically, he or she shall be directed to the
appropriate contact person. Any change in the designated contact shall not be
effective until the carrier, self-insured employer or third-party administrator
has updated the designated contact information in the Board's electronic
records.
3. In the event that a
carrier or self-insured employer fails to provide the Chair or his or her
designee with such name and contact information (in the manner prescribed)
within six months of the effective date of this Subpart, or provides incorrect
or incomplete contact information during initial registration or when updating
pursuant to subparagraph (1) of this subdivision, such carrier may be subject
to:
i. Orders of the Chair approving Prior
Authorizations submitted during such time when the name and contact information
is missing, incomplete or incorrect; and
ii. Penalties issued pursuant to section
114-a(3) of the Workers' Compensation Law for every case, where Prior
Authorization was requested.
(g) To initiate the Prior Authorization process, the
medical provider shall submit a request for Prior Authorization to the
insurance carrier, self-insured employer, or third-party administrator to the
designated contact as described in subdivision (d) herein. Such request shall
be submitted in the manner prescribed by the Chair.
1. The carrier, self-insured employer, or
third-party administrator shall approve, partially approve or deny a Prior
Authorization request within four calendar days of submission by a provider.
The carrier, self-insured employer or third-party administrator shall send the
claimant notice of the approval, partial approval or denial of the prior
authorization request. 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
i. A partial approval means the carrier,
self-insured employer or third-party administrator:
(A) authorizes durable medical equipment with
a different HCPCS code than was requested; or,
(B) when a rental was requested, authorizes
rental of the requested durable medical equipment for less than the requested
duration; or
(C) authorizes
durable medical equipment not listed on the Official New York State Durable
Medical Equipment Fee Schedule at a lesser purchase price than requested by the
medical provider; or when the carrier approves rental of durable medical
equipment instead of purchase of such equipment.
ii. A request for Prior Authorization that
is not responded to within four calendar days (by an approval, denial or
partial approval) may be approved upon issuance of an Order of the Chair 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. A carrier may not object to payment in accordance with section
325-1.25
of this Chapter for Durable Medical Equipment approved by an Order of the Chair
and any such objection or non-payment may be subject to penalties pursuant to
section 114-a(3) of the Workers' Compensation Law.
iii. If the insurance carrier, self-insured
employer or third-party administrator concedes the medical necessity of the
medical care, it may approve the durable medical equipment prior authorization
request without liability, only if the case has been controverted in accordance
with section
300.22(b)(1)(ii)
or (c)(1) of this Chapter, or the durable
medical equipment is for a body part or condition that has not been accepted by
the insurance carrier, self-insured employer or third-party administrator or
established by the Board.
iv. In
the event the prior authorization request is submitted prior to creation of a
workers' compensation case by the Board in accordance with 300.37(a) of this
Chapter, the prior authorization request will be promptly reviewed by the Board
to identify the proper carrier, self-insured employer or third-party
administrator. Upon such identification, the prior authorization request will
be directed by the Board to the proper carrier, self-insured employer, or
third-party administrator, who shall have 4 calendar days to approve, partially
approve or deny the request. In the event the prior authorization request 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 4 calendar days to approve, partially
approve or deny the request. In the event the prior authorization request 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.
2. A partial
approval or denial of a request for Prior Authorization must:
i. Be issued by the Carrier's Physician
(defined in subdivision (g) of section
441.1 of
this Subchapter) unless:
(A) such request is
for durable medical equipment that is the subject of an earlier prior
authorization request that has been denied or has not yet been acted upon;
(B) such request for durable
medical equipment for a case that is closed, disallowed or cancelled, settled
via section 32 of the Workers' Compensation Law, or controverted in accordance
with section
300.22(b)(1)(ii)
or (c)(1) of this Chapter. Such prior
authorization requests for durable medical equipment may be denied without
review by the Carrier's Physician;
ii. Provide a specific reason for the denial or partial approval
with reference to the specific Prior Authorization request made by the medical
provider;
iii. When the partial
approval reduces the durable medical equipment price requested by the medical
provider, the partial approval must:
(A)
identify two sources of the adjusted price, including the address and phone
number of the source, and the reason for such adjustment; and,
(B) the durable medical equipment must be
available at a supplier located within 15 miles of the claimant's place of
residence or employment if the claimant resides in a rural area as that term is
defined in section
440.2 of
this chapter, or within five miles of the claimant's place of residence or
employment if the claimant resides in a municipality which is an incorporated
city or village having a population of 2,500 or more, or the durable medical
equipment must be delivered to the claimant's residence; and
(C) such durable medical equipment must be
delivered or supplied completely assembled and useable without further fittings
within 48 hours.
iv.
Provide information regarding how to request review of the denial from the
Board's Medical Director's Office.
3. Unless the insurance carrier, self-insured
employer or third-party administrator has properly denied, or granted as to
medical necessity but withheld liability for the claim, the carrier may not
thereafter object to payment for such durable medical equipment at the fee
schedule rate and any such objections will be rejected by the Board and
applicable penalties imposed.
(h) All communications regarding Prior Authorization,
including communications pursuant to sections 442.4 and 442.5 of this Part,
shall be by the means of electronic delivery the Chair has designated for this
purpose.
Adopted
New
York State Register March 3, 2021/Volume XLIII, Issue 09, eff.
6/7/2021