Subpart 325-1 — General

Aggregated from public-domain New York law; no amendment recorded since codification.

When a physician, in association or in copartnership with another physician or physicians, or through another physician or physicians as employees or agents, maintains and operates one or more offices principally for the treatment of injured claimants under the Workers' Compensation Law, he or she shall apply for a compensation medical bureau license.

Aggregated from public-domain New York law; no amendment recorded since codification.

All specialists and consultants, except independent medical examiners, shall file the reports prescribed for attending physicians under section 325-1.3 of this Subpart with the board, claimant, the claimant's attending physician, the claimant's legal representative, if any, and the employer or insurance carrier.

Aggregated from public-domain New York law; last amended effective 2020-10-14.

(a) All medical reports filed by treating providers and specialists must be submitted to the insurance carrier, self-insured employer, or third-party administrator and the Board in the format prescribed by the Chair, which may be electronic.

(b) Every provider shall file all medical reports with the Chair, and also with the employer or the employer's carrier, if known, in the format prescribed by the Chair, which may be electronic, in the following intervals: (1) within 48 hours following first treatment; (2) within 15 days after filing the medical report filed within 48 hours after the first treatment; (3) thereafter during continuing treatment and without further request, a progress report for each follow-up visit to be scheduled when medically necessary except the intervals between follow-up visits shall be no more than 90 days; (4) when a claimant reaches the maximum medical improvement, which must include an opinion whether there is any permanent impairment, if any;

(1) within 48 hours following first treatment;

(2) within 15 days after filing the medical report filed within 48 hours after the first treatment;

(3) thereafter during continuing treatment and without further request, a progress report for each follow-up visit to be scheduled when medically necessary except the intervals between follow-up visits shall be no more than 90 days;

(4) when a claimant reaches the maximum medical improvement, which must include an opinion whether there is any permanent impairment, if any;

(c) Carriers, self-insured employers and third-party administrators may designate a single mailing address for mailing of paper medical reports and bills when such address has been published in the manner prescribed by the Chair and the provider is provided with actual notice of the mailing address.

Aggregated from public-domain New York law; last amended effective 2021-06-07.

(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).

(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.

(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.

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.

(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.

(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.

(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.

(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.

Aggregated from public-domain New York law; no amendment recorded since codification.

The authority of an employer or carrier to authorize the services of a specialist in excess of a fee of $1,000 applies only to the necessity for such services, but the choice of such specialist is entirely the choice of the injured worker, unless the employer or carrier has a contract with a diagnostic testing network or networks, requires an injured worker to utilize a provider or facility affiliated with such diagnostic testing network or networks and has furnished the notification required by section 325-7.5(d) of this Part.

Aggregated from public-domain New York law; last amended effective 2018-01-01.

(a) All evaluations of permanent impairment for use in a schedule loss of use determination shall be performed in accordance with the Workers' Compensation Guidelines for Determining Impairment, First Edition, XXXXXXX, effective January 1, 2018, which is herein incorporated by reference. Such evaluations must be completed in the format prescribed by the chair.

(b) Obtaining the Workers' Compensation Guidelines for Determining Impairment. The Workers' Compensation Guidelines for Determining Impairment incorporated by reference herein may be examined at the office of the Department of State, 99 Washington Avenue, Albany, NY 12231, the Legislative Library, the libraries of the New York State Supreme Court, and the district offices of the board. Copies may be downloaded from the board's website or obtained from the board by submitting a request in writing, with the appropriate fee, identifying the specific guideline requested and the choice of format to Publications, New York State Workers' Compensation Board, 328 State Street, Schenectady, NY 12305-2318. Information about the Workers' Compensation Guidelines for Determining Impairment can be requested by email at [email protected], or by telephone at 1-800-781-2362. The Workers' Compensation Guidelines for Determining Impairment are available on paper or compact disc. A fee of $10 will be charged for the guideline requested in paper format, and a fee of $5 will be charged for a compact disc. Payment of the fee shall be made by check or money order payable to "Chair WCB."

Aggregated from public-domain New York law; no amendment recorded since codification.

A physician authorized to treat workers' compensation cases, when requested to supersede another physician, must, before beginning treatment of such patient, make reasonable effort to communicate with the attending physician to ascertain the patient' s condition. The superseding physician must also advise the attending physician of the name of the person who has requested him or her to assume care of the case and state the reason therefor. If the superseding physician cannot contact the attending physician, and the claimant's condition requires immediate treatment, the superseding physician should advise the physician previously in attendance within 48 hours that he or she now has the patient in his or her care. The preceding physician shall supply the superseding physician with a complete history of the case.

Aggregated from public-domain New York law; last amended effective 2023-04-11.

(a) In the event of a serious accident requiring immediate emergency medical aid, an ambulance or any physician may be called to give first aid treatment.

(b) Telemedicine, using an interactive audio and video telecommunications system that permits real-time communication between an authorized medical provider and a claimant in accordance with guidance from the Centers for Medicare & Medicaid Services, may be used by authorized providers where medically appropriate for social distancing purposes due to the outbreak of COVID-19 to assess current disability status. "Medically appropriate" includes discussion of test results or imaging, follow-up assessments, or counseling. It does not include treatment where physical examination is a necessary component, such as initial visits or assessments, physical therapy or other types of manual therapy. The authorized provider shall indicate on their report that such assessment was done using telemedicine as a result of social distancing due to the outbreak of COVID-19.

Aggregated from public-domain New York law; no amendment recorded since codification.

Bills for X-ray and consultation rendered by a specialist and bills for X-ray examination, diagnosis or treatment rendered by an X-ray laboratory or bureau of a voluntary hospital licensed by the chair shall be submitted for payment directly to the employer or carrier. These services must be authorized in writing by the physician in attendance.

Aggregated from public-domain New York law; no amendment recorded since codification.

(a) Physicians treating claimants in hospitals may secure the signature of claimant for authorization to obtain copies of any necessary hospital records.

(b) Employers, carriers, claimant's representatives or special funds upon written request to any hospital operating in New York State together with the claimant' s written consent, may obtain for use in board proceedings, the hospital records of a claimant pertaining to his or her compensation claim.

(c) Written notice of such request together with proof of mailing shall be provided to the board.

(d) A hospital has 20 days to respond to such request by either: (1) providing the records; or (2) notifying in writing the party requesting the records that such records cannot be provided and the reason for not providing such records together with the date upon which the records will be provided. Such date shall not be more than 30 days from the date of the written request.

(1) providing the records; or

(2) notifying in writing the party requesting the records that such records cannot be provided and the reason for not providing such records together with the date upon which the records will be provided. Such date shall not be more than 30 days from the date of the written request.

(e) Failure to provide the records or a reason why the records have not been provided in 20 days from written request by a party shall subject the hospital to a fine of $200 imposed by the chair payable into the board's administrative funds.

(f) Failure by the hospital to provide the records in 30 days after notification to the requesting party of the reason for not initially providing such record and the date on which such records would be produced shall subject the hospital to a fine of $200 imposed by the chair payable into the board's administrative funds.

(g) No hospital shall be required to produce the records of any claimant pursuant to this section without receiving its customary fees or charges for reproduction of such records.

Aggregated from public-domain New York law; no amendment recorded since codification.

The physician in attendance in public hospitals must be the judge as to when the "emergency status" of the case has terminated. In case of a dispute, the matter shall be referred to the compensation board of the medical society of the county in which the hospital is located for immediate decision.

Aggregated from public-domain New York law; no amendment recorded since codification.

Medical inspectors of insurance companies shall be admitted to hospitals or other institutions where injured employees are confined, upon proper identification, for the purpose of complying with section 13-j of the Workers' Compensation Law.

Aggregated from public-domain New York law; no amendment recorded since codification.

No license is required for an employer to operate a first aid station for emergency treatment, but no subsequent treatments are to be rendered by anyone, other than a qualified physician on the minimum fee schedule basis.

Aggregated from public-domain New York law; no amendment recorded since codification.

(a) A physician shall not advertise or publicize himself or herself in violation of any statute or rule of court or the Workers' Compensation Law and the rules and regulations promulgated thereunder.

(b) A physician on behalf of himself or herself, or partners or associates, shall not use or disseminate or participate in the preparation or dissemination of any public communication containing statements or claims that are false, deceptive or misleading.

(c) Advertising or other publicity by physicians, including participation in public functions, shall not contain puffery, self-laudation, claims regarding the quality of the physician's medical services, or claims that cannot be measured or verified.

(d) It is proper to include information, provided its dissemination does not violate the provisions of subdivisions (b) and (c) of this section, as to education, degrees and other scholastic distinctions; dates of admission to practice; areas of medicine in which the physician practices, and teaching positions held; memberships in medical associations or other professional societies or organizations, including offices and committee assignments therein; foreign language fluency.

(e) Advertising and publicity shall be designed to educate the public to an awareness of medical needs and to provide information relevant to the selection of the most appropriate physician. Information, other than that specifically authorized in subdivision (d) of this section, that is consistent with these purposes may be disseminated providing that it does not violate any other provisions of this section.

(f) If the advertisement is broadcast, it shall be prerecorded or taped and approved for broadcast by the physician, and a recording or videotape of the actual transmission shall be retained by the physician for a period of not less than one year following such transmission.

Aggregated from public-domain New York law; no amendment recorded since codification.

No insurance company or self-insurer may reduce the size of notice to employees (form C-105) which is to be posted in all places of employment covered by the Workers' Compensation Law, unless such permission is granted on application to the chair.

Aggregated from public-domain New York law; no amendment recorded since codification.

A physician who testifies at hearings or examines claimants or participates in examinations for evidential material for compensation case hearing purposes only, may accept fees for such services from claimants, employers or carriers.

Aggregated from public-domain New York law; no amendment recorded since codification.

Hospitals may render bills for board and room accommodations, medical and surgical supplies and nursing facilities. Voluntary hospitals may bill for X-ray services when rendered by an X-ray laboratory or bureau of such hospital duly licensed by the chair. Hospitals may bill for physiotherapeutic, anesthesia and pathologic services when rendered by or under the supervision of salaried physicians on the staff. The names and qualifications of all physicians and persons rendering services for which charges are made by hospitals must be included in all bills, and all medical and X-ray reports shall be promptly filed with the board and with the employer or its insurance carrier.

Aggregated from public-domain New York law; no amendment recorded since codification.

(a) In the case of a physician's or hospital's bill, the treatment or services shall have been furnished on or after July 27, 1976. In the case of a self-employed physical or occupational therapist's, podiatrist's or chiropractor's bill, the treatment or services shall have been furnished on or after January 1, 1987. In the case of a psychologist' s bill, the treatment or services shall have been furnished on or after January 1, 1990. In all cases the treatment or services shall have been performed prior to October 1, 1994.

(b) The physician's, self-employed physical or occupational therapist's, podiatrist's, chiropractor's or psychologist's bill shall have been submitted to the employer or carrier within 90 days from the last day of the month in which the services were rendered; the hospital's bill shall have been submitted to such parties within 120 days from the last day of the month in which the services were rendered.

(c) Only in the event that the courts, on appeal, disallow a claim for workers' compensation shall the employer or carrier be entitled to reimbursement, in accordance with the provisions of section 23 of the Workers' Compensation Law, for such fair and reasonable doctors' bills paid by the employer or carrier pending the outcome of the appeal.

(d) In the case of treatment or services performed on or after October 1, 1994, regardless of the date of accident or occupational disease, the making of an award for unpaid bills for such services shall be subject to section 325-1.24 of this Subpart.

Aggregated from public-domain New York law; no amendment recorded since codification.

(a) shall accept and treat such injured employees in a manner corresponding to that accorded other patients in his or her practice, without discriminating against such injured employees because they are or may be covered by the provisions of the Workers' Compensation Law; and

(b) shall not refuse to provide treatment and care to such injured employees on the basis of a fee request greater than that set forth in the applicable prescribed fee schedule, but shall submit to arbitration such fee dispute in accordance with the provisions of the Workers' Compensation Law, nor shall such treatment and care be denied to such injured employees because the source or manner of payment for such treatment and care is pursuant to the provisions of the Workers' Compensation Law. Nothing contained in this section shall prevent a voluntary payment by the employer or carrier of an amount higher than the fees and charges found in the fee schedule where agreed to by the employer or carrier. An authorized physician, podiatrist, chiropractor, psychologist, operator of a medical bureau or laboratory whose actions violate or are inconsistent with the provisions of this section shall be charged with misconduct, and his or her authorization to treat workers' compensation cases shall be subject to suspension or revocation by the chair in accordance with the procedures set forth in the Workers' Compensation Law.

Aggregated from public-domain New York law; no amendment recorded since codification.

The special fund, by its duly designated representative under section 25-a of the Workers' Compensation Law, when objecting to a bill rendered by a physician, hospital, podiatrist, chiropractor, psychologist, or self-employed occupational or physical therapist, shall comply with all of the applicable provisions of sections 13-g, 13-k, 13-l and 13-m of the Workers' Compensation Law and the rules and regulations promulgated thereunder.

Aggregated from public-domain New York law; no amendment recorded since codification.

An authorized doctor or an occupational or physical therapist treating a workers' compensation claimant may require the claimant to sign an agreement, on a prescribed form, requiring such claimant to pay said doctor or therapist his or her usual and customary fees for services rendered to such claimant, in the event said claimant fails to prosecute a claim for workers' compensation for such illness or condition, or in the event it is determined by the Workers' Compensation Board that the illness or condition for which such services were rendered was not the result of a compensable workers' compensation claim.

Aggregated from public-domain New York law; last amended effective 2021-11-01.

(a) Obligation and liability of employer or insurance carrier (or third-party administrator) to provide Medical Care. (1) The employer or insurance carrier (or third-party administrator) is required to promptly provide the claimant with such Medical Care, for such period as the nature of the injury, illness, or occupational disease, or process of recovery may require. Medical Care means symptomatic, palliative, maintenance treatment, services, or supplies. When the Medical Care is to or for a part of the body or condition covered by the Medical Treatment Guidelines as set forth in section 324.2(a) of this Title, the employer or insurance carrier (or third-party administrator) is required to provide such Medical Care which is consistent with the Medical Treatment Guidelines or, if applicable, an approved variance from such guidelines. (2) The employer or insurance carrier (or third-party administrator) is liable for the payment of medically necessary care, services, and supplies to the claimant when it has accepted the claim or the claim has been established as compensable by the Board. When the Medical Care is to or for a part of the body covered by the Medical Treatment Guidelines and the claim has been accepted or established as compensable, the employer or insurance carrier (or third-party administrator) shall be obligated to pay for all Medical Care, in the amount set forth in the applicable fee schedule, or in any other amount as agreed to by the Treating Medical Provider and payor, that is: (i) within the criteria of the medical treatment guidelines incorporated by reference pursuant to section 324.2(a) of this Title and is based on correct application of such guidelines; (ii) within a proper variance from the Medical Treatment Guidelines in accordance with the requirements of section 324.3(a) (2), or has been authorized pursuant to section 325-1.4 or Part 441of this Title; (iii) agreed to by the employer or insurance carrier (or third-party administrator); or (iv) as ordered by the Board pursuant to statute or regulation. The employer or insurance carrier (or third-party administrator) shall not be obligated to pay for any Medical Care that is not within the criteria of the Medical Treatment Guidelines or is not based on correct application of the Medical Treatment Guidelines, except if a variance has been approved by the employer, insurance carrier (or third-party administrator), or Board in accordance with section 324.3 of this Title or as ordered by the Board pursuant to statute or regulation.

(1) The employer or insurance carrier (or third-party administrator) is required to promptly provide the claimant with such Medical Care, for such period as the nature of the injury, illness, or occupational disease, or process of recovery may require. Medical Care means symptomatic, palliative, maintenance treatment, services, or supplies. When the Medical Care is to or for a part of the body or condition covered by the Medical Treatment Guidelines as set forth in section 324.2(a) of this Title, the employer or insurance carrier (or third-party administrator) is required to provide such Medical Care which is consistent with the Medical Treatment Guidelines or, if applicable, an approved variance from such guidelines.

(2) The employer or insurance carrier (or third-party administrator) is liable for the payment of medically necessary care, services, and supplies to the claimant when it has accepted the claim or the claim has been established as compensable by the Board. When the Medical Care is to or for a part of the body covered by the Medical Treatment Guidelines and the claim has been accepted or established as compensable, the employer or insurance carrier (or third-party administrator) shall be obligated to pay for all Medical Care, in the amount set forth in the applicable fee schedule, or in any other amount as agreed to by the Treating Medical Provider and payor, that is: (i) within the criteria of the medical treatment guidelines incorporated by reference pursuant to section 324.2(a) of this Title and is based on correct application of such guidelines; (ii) within a proper variance from the Medical Treatment Guidelines in accordance with the requirements of section 324.3(a) (2), or has been authorized pursuant to section 325-1.4 or Part 441of this Title; (iii) agreed to by the employer or insurance carrier (or third-party administrator); or (iv) as ordered by the Board pursuant to statute or regulation. The employer or insurance carrier (or third-party administrator) shall not be obligated to pay for any Medical Care that is not within the criteria of the Medical Treatment Guidelines or is not based on correct application of the Medical Treatment Guidelines, except if a variance has been approved by the employer, insurance carrier (or third-party administrator), or Board in accordance with section 324.3 of this Title or as ordered by the Board pursuant to statute or regulation.

(i) within the criteria of the medical treatment guidelines incorporated by reference pursuant to section 324.2(a) of this Title and is based on correct application of such guidelines;

(ii) within a proper variance from the Medical Treatment Guidelines in accordance with the requirements of section 324.3(a) (2), or has been authorized pursuant to section 325-1.4 or Part 441of this Title;

(iii) agreed to by the employer or insurance carrier (or third-party administrator); or

(iv) as ordered by the Board pursuant to statute or regulation. The employer or insurance carrier (or third-party administrator) shall not be obligated to pay for any Medical Care that is not within the criteria of the Medical Treatment Guidelines or is not based on correct application of the Medical Treatment Guidelines, except if a variance has been approved by the employer, insurance carrier (or third-party administrator), or Board in accordance with section 324.3 of this Title or as ordered by the Board pursuant to statute or regulation.

(b) Submission of bills for Medical Care. (1) Physicians, podiatrists, chiropractors, psychologists, nurse practitioners, physician assistants, licensed clinical social workers, physical therapists, occupational therapists and acupuncturists authorized by the Chair to provide treatment and care under the Workers' Compensation Law to a claimant or other legally permitted providers of Medical Care shall submit bills for Medical Care in the format prescribed by the Chair (which may be electronic) and as set forth in section 325-1.3 of this Subpart. Bills shall be submitted to the employer or insurance carrier (or third-party administrator) within 120 days from the day the Medical Care was rendered. Bills submitted in any other format or outside this time requirement shall not be eligible for an award by the Chair under the provisions of the Workers' Compensation Law as described herein. When Medical Care was rendered prior to January 1, 2020, the bill for such care shall be submitted within 120 days from January 1, 2020 (April 30, 2020). (2) Hospitals shall submit bills for out-patient hospital services to the employer or insurance carrier (or third-party administrator) using the New York State Universal Data Set specification as described in 10 NYCRR section 400.18 and Appendices C-2 and C-3 and such additional specifications as are approved by the Commissioner of Health. Bills shall be submitted within 120 days from the last day of Medical Care. Bills submitted in any other format or outside this time requirement shall not be eligible for an award by the Chair under the provisions of the Workers' Compensation Law as described herein. (3) Notwithstanding the foregoing, upon an application in writing to the Chair, the Chair may for good cause shown excuse a delay in the submission of the bill to the insurance carrier or employer (or third-party administrator).

(1) Physicians, podiatrists, chiropractors, psychologists, nurse practitioners, physician assistants, licensed clinical social workers, physical therapists, occupational therapists and acupuncturists authorized by the Chair to provide treatment and care under the Workers' Compensation Law to a claimant or other legally permitted providers of Medical Care shall submit bills for Medical Care in the format prescribed by the Chair (which may be electronic) and as set forth in section 325-1.3 of this Subpart. Bills shall be submitted to the employer or insurance carrier (or third-party administrator) within 120 days from the day the Medical Care was rendered. Bills submitted in any other format or outside this time requirement shall not be eligible for an award by the Chair under the provisions of the Workers' Compensation Law as described herein. When Medical Care was rendered prior to January 1, 2020, the bill for such care shall be submitted within 120 days from January 1, 2020 (April 30, 2020).

(2) Hospitals shall submit bills for out-patient hospital services to the employer or insurance carrier (or third-party administrator) using the New York State Universal Data Set specification as described in 10 NYCRR section 400.18 and Appendices C-2 and C-3 and such additional specifications as are approved by the Commissioner of Health. Bills shall be submitted within 120 days from the last day of Medical Care. Bills submitted in any other format or outside this time requirement shall not be eligible for an award by the Chair under the provisions of the Workers' Compensation Law as described herein.

(3) Notwithstanding the foregoing, upon an application in writing to the Chair, the Chair may for good cause shown excuse a delay in the submission of the bill to the insurance carrier or employer (or third-party administrator).

(c) Payment of bills for Medical Care. (1) The employer or insurance carrier (or third-party administrator), within 45 days after the bill has been received shall pay the bill or shall notify the physician, occupational or physical therapist, podiatrist, chiropractor, psychologist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital, or other provider of Medical Care, the claimant and claimant's attorney if applicable, and the Board in the format prescribed by the Chair (which may be electronic) for such purpose that the bill is not being paid and the reasons for non-payment. If the employer or insurance carrier (or third-party administrator) objects to payment of all or part of the bill for reasons concerning its legal liability for payment, the legal objections shall be made in the format prescribed by the Chair for such purpose and submitted to the physician, occupational or physical therapist, podiatrist, chiropractor, psychologist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital, or other provider of Medical Care, the claimant and claimant's attorney if applicable, and the Board simultaneously with any other objections to the bill. If the employer or insurance carrier (or third-party administrator) objects to payment of all or part of the bill for reasons concerning the value of the treatment performed or the amount billed, the valuation objections shall be made in the format prescribed by the Chair for that purpose and submitted to the physician, occupational or physical therapist, podiatrist, chiropractor, psychologist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital, or other provider of Medical Care, the claimant and claimant's attorney if applicable, and the Board simultaneously with any other objections to the bill. However, if the only objection is that the amount billed for the particular Current Procedural Terminology (CPT) code is in excess of the appropriate fee schedule for the region where the services were provided, the insurance carrier or employer (or third-party administrator) may instead file its explanation of benefits form. If the employer or insurance carrier (or third-party administrator) objects to payment of all or part of the bill for one or more of the Medical Treatment Guidelines objections set forth in paragraph (7) of this subdivision, the objections shall be placed in the format prescribed by the Chair (which may be electronic), along with the basis for the objection, and submitted to the physician, occupational or physical therapist, podiatrist, chiropractor, or psychologist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital, or other provider of Medical Care, the claimant and claimant's attorney if applicable, and the Board simultaneously with any other objections to the bill. (2) If the employer or insurance carrier (or third-party administrator) objects to only a portion of the bill submitted, it shall pay the uncontested portion within 45 days and file objections to the remaining portion as indicated herein. (3) If the employer or insurance carrier (or third-party administrator) has not objected in the manner described herein to the payment of the bill within 45 days of submission, it shall be liable for payment of the full amount billed up to the maximum amount established in the applicable fee schedule. The Board shall not review any objection made thereafter. (4) Legal, valuation, and Medical Treatment Guidelines objections shall be made simultaneously in the format prescribed by the Chair (which may be electronic). (5) Valuation objections as to the amount of the bill include, but are not limited to, contentions that the bill is excessive and not in accordance with the pertinent fee schedule; has not been properly pro-rated or apportioned between providers; involves concurrent, duplicative, or overlapping services; uses improper current procedural terminology codes; is not in accordance with the Ground Rules limitation in the appropriate official workers' compensation fee schedule; is rendered too frequently; involves unnecessary or excessive hospitalization; or involves a physician, occupational or physical therapist, podiatrist, chiropractor, psychologist, nurse practitioner, physician assistant, licensed clinical social worker or acupuncturist treating outside the scope of practice. (6) Legal objections as to the liability of the employer or insurance carrier (or third-party administrator) to pay include, but are not limited to, contentions that the claim has been controverted and liability has not been resolved; prior authorization for the special medical service was not granted; treatment was not causally related to the compensable injury; treatment provided was outside of the preferred provider organization; the medical report was not timely filed or was legally defective; the medical appliance, program, or provider is not authorized under the Workers' Compensation Law; or the bill is for evidentiary purposes and not for treatment. Pursuant to Workers' Compensation Law section 13(a), raising the issue of liability under Workers' Compensation Law section 25-a is not a valid legal objection to payment of a bill for treatment. A legal objection that was not properly raised in response to any applicable prior authorization request will be denied. The employer or insurance carrier (or third-party administrator) shall attach or identify the denial made to any applicable prior authorization request to its legal objection. (7) The Medical Treatment Guidelines objections as to the liability of the employer or insurance carrier (or third-party administrator) to pay are:(i) the treatment is not consistent with the Medical Treatment Guidelines and a variance was not requested or approved by the employer or insurance carrier (or third-party administrator), or the Board before the Medical Care was rendered; (ii) the physician, podiatrist, chiropractor, psychologist, nurse practitioner, licensed clinical social worker, or hospital varied from the Medical Treatment Guidelines, the physician, podiatrist, chiropractor, psychologist, nurse practitioner, licensed clinical social worker, hospital, or other provider of Medical Care, requested and received approval for a variance from the employer or insurance carrier (or third-party administrator) or the Board before the Medical Care was rendered but provided Medical Care other than what was covered by the variance; or (iii) the physician, occupational or physical therapist, podiatrist, chiropractor, psychologist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital or other legally permitted Medical Care provider misapplied the Medical Treatment Guidelines. (iv) A Medical Treatment Guideline objection that was not properly raised in response to any applicable prior authorization request will be denied. The employer or insurance carrier (or third-party administrator) shall attach or identify the denial made to any applicable prior authorization request to its legal objection.

(1) The employer or insurance carrier (or third-party administrator), within 45 days after the bill has been received shall pay the bill or shall notify the physician, occupational or physical therapist, podiatrist, chiropractor, psychologist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital, or other provider of Medical Care, the claimant and claimant's attorney if applicable, and the Board in the format prescribed by the Chair (which may be electronic) for such purpose that the bill is not being paid and the reasons for non-payment. If the employer or insurance carrier (or third-party administrator) objects to payment of all or part of the bill for reasons concerning its legal liability for payment, the legal objections shall be made in the format prescribed by the Chair for such purpose and submitted to the physician, occupational or physical therapist, podiatrist, chiropractor, psychologist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital, or other provider of Medical Care, the claimant and claimant's attorney if applicable, and the Board simultaneously with any other objections to the bill. If the employer or insurance carrier (or third-party administrator) objects to payment of all or part of the bill for reasons concerning the value of the treatment performed or the amount billed, the valuation objections shall be made in the format prescribed by the Chair for that purpose and submitted to the physician, occupational or physical therapist, podiatrist, chiropractor, psychologist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital, or other provider of Medical Care, the claimant and claimant's attorney if applicable, and the Board simultaneously with any other objections to the bill. However, if the only objection is that the amount billed for the particular Current Procedural Terminology (CPT) code is in excess of the appropriate fee schedule for the region where the services were provided, the insurance carrier or employer (or third-party administrator) may instead file its explanation of benefits form. If the employer or insurance carrier (or third-party administrator) objects to payment of all or part of the bill for one or more of the Medical Treatment Guidelines objections set forth in paragraph (7) of this subdivision, the objections shall be placed in the format prescribed by the Chair (which may be electronic), along with the basis for the objection, and submitted to the physician, occupational or physical therapist, podiatrist, chiropractor, or psychologist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital, or other provider of Medical Care, the claimant and claimant's attorney if applicable, and the Board simultaneously with any other objections to the bill.

(2) If the employer or insurance carrier (or third-party administrator) objects to only a portion of the bill submitted, it shall pay the uncontested portion within 45 days and file objections to the remaining portion as indicated herein.

(3) If the employer or insurance carrier (or third-party administrator) has not objected in the manner described herein to the payment of the bill within 45 days of submission, it shall be liable for payment of the full amount billed up to the maximum amount established in the applicable fee schedule. The Board shall not review any objection made thereafter.

(4) Legal, valuation, and Medical Treatment Guidelines objections shall be made simultaneously in the format prescribed by the Chair (which may be electronic).

(5) Valuation objections as to the amount of the bill include, but are not limited to, contentions that the bill is excessive and not in accordance with the pertinent fee schedule; has not been properly pro-rated or apportioned between providers; involves concurrent, duplicative, or overlapping services; uses improper current procedural terminology codes; is not in accordance with the Ground Rules limitation in the appropriate official workers' compensation fee schedule; is rendered too frequently; involves unnecessary or excessive hospitalization; or involves a physician, occupational or physical therapist, podiatrist, chiropractor, psychologist, nurse practitioner, physician assistant, licensed clinical social worker or acupuncturist treating outside the scope of practice.

(6) Legal objections as to the liability of the employer or insurance carrier (or third-party administrator) to pay include, but are not limited to, contentions that the claim has been controverted and liability has not been resolved; prior authorization for the special medical service was not granted; treatment was not causally related to the compensable injury; treatment provided was outside of the preferred provider organization; the medical report was not timely filed or was legally defective; the medical appliance, program, or provider is not authorized under the Workers' Compensation Law; or the bill is for evidentiary purposes and not for treatment. Pursuant to Workers' Compensation Law section 13(a), raising the issue of liability under Workers' Compensation Law section 25-a is not a valid legal objection to payment of a bill for treatment. A legal objection that was not properly raised in response to any applicable prior authorization request will be denied. The employer or insurance carrier (or third-party administrator) shall attach or identify the denial made to any applicable prior authorization request to its legal objection.

(7) The Medical Treatment Guidelines objections as to the liability of the employer or insurance carrier (or third-party administrator) to pay are:(i) the treatment is not consistent with the Medical Treatment Guidelines and a variance was not requested or approved by the employer or insurance carrier (or third-party administrator), or the Board before the Medical Care was rendered; (ii) the physician, podiatrist, chiropractor, psychologist, nurse practitioner, licensed clinical social worker, or hospital varied from the Medical Treatment Guidelines, the physician, podiatrist, chiropractor, psychologist, nurse practitioner, licensed clinical social worker, hospital, or other provider of Medical Care, requested and received approval for a variance from the employer or insurance carrier (or third-party administrator) or the Board before the Medical Care was rendered but provided Medical Care other than what was covered by the variance; or (iii) the physician, occupational or physical therapist, podiatrist, chiropractor, psychologist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital or other legally permitted Medical Care provider misapplied the Medical Treatment Guidelines. (iv) A Medical Treatment Guideline objection that was not properly raised in response to any applicable prior authorization request will be denied. The employer or insurance carrier (or third-party administrator) shall attach or identify the denial made to any applicable prior authorization request to its legal objection.

(i) the treatment is not consistent with the Medical Treatment Guidelines and a variance was not requested or approved by the employer or insurance carrier (or third-party administrator), or the Board before the Medical Care was rendered;

(ii) the physician, podiatrist, chiropractor, psychologist, nurse practitioner, licensed clinical social worker, or hospital varied from the Medical Treatment Guidelines, the physician, podiatrist, chiropractor, psychologist, nurse practitioner, licensed clinical social worker, hospital, or other provider of Medical Care, requested and received approval for a variance from the employer or insurance carrier (or third-party administrator) or the Board before the Medical Care was rendered but provided Medical Care other than what was covered by the variance; or

(iii) the physician, occupational or physical therapist, podiatrist, chiropractor, psychologist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital or other legally permitted Medical Care provider misapplied the Medical Treatment Guidelines.

(iv) A Medical Treatment Guideline objection that was not properly raised in response to any applicable prior authorization request will be denied. The employer or insurance carrier (or third-party administrator) shall attach or identify the denial made to any applicable prior authorization request to its legal objection.

(d) Administrative award: a remedy for non-payment of bills when no timely valuation objections are raised. (1) Chair authorized physicians, podiatrists, chiropractors, psychologists, nurse practitioners, physician assistants, licensed clinical social workers, acupuncturists, occupational or physical therapists, and other legally permitted providers of Medical Care, or hospitals providing services to claimants who have timely submitted bills for payment to the insurance carrier or employer (or third-party administrator) and who have not been paid in full or in part or received notice in the format prescribed by the Chair (which may be electronic) for the purpose of advising of a valuation reason for non-payment within the time prescribed above, may apply to the Chair the prescribed format (which may be electronic) for an administrative award pursuant to the provisions of Workers' Compensation Law sections 13-g(1), 13-k(6), 13-l(6) and 13-m(7). Such request shall be submitted no earlier than 45 days from the date of the submission of the bill or 30 days from the date of the Workers' Compensation Law Judge or conciliation decision, or if appeal, Board Panel decision establishing the insurance carrier's or employer's (or third-party administrator's) liability for the bill, and within 120 days from the later of: (i) the date of receipt of notification of nonpayment; or (ii) the expiration of the time within which the insurance carrier or employer (or third-party administrator) is required to notify the physician, self-employed occupational or physical therapist, podiatrist, chiropractor, psychologist, or hospital of nonpayment. (2) Notwithstanding the foregoing, upon a written application of the physician, occupational or physical therapist, podiatrist, chiropractor, psychologist, nurse practitioners, physician assistants, licensed clinical social workers, acupuncturists, hospital, or other provider of Medical Care, the Chair may for good cause shown excuse a delay in the submission of the request for an administrative award (3) (i) The Board will not accept any request for an administrative award until thirty days after all issues duly and timely raised by the employer or insurance carrier (or third-party administrator) with respect to its legal liability for payment and/or any Medical Treatment Guidelines objections set forth in paragraph (c)(7) of this section have been finally determined adversely to it. (ii) A provider may only submit one request for an administrative award for each date of service. A request for administrative award that includes a date of service that was included on a previously submitted request for administrative award will be rejected. (4) All requests for administrative awards shall be submitted to the Chair or his or her designee in the format prescribed for such purpose and certifies the following information: (i) the bill was timely submitted to the employer or insurance carrier (or third-party administrator) and the bill was not returned; (ii) the employer or insurance carrier (or third-party administrator) did not submit payment within 45 days after the bill was submitted or within 30 days after all questions duly and timely raised related to the employer or insurance carrier (or third-party administrator)'s liability therefore was finally determined adversely to it; (iii) the employer or insurance carrier (or third-party administrator) did not raise valuation issues in the format prescribed by the Chair objecting to payment of the bill; (iv) the bill conforms to the fee schedule, if any, promulgated by the chair for treatment rendered; and (v) the bill was submitted in the format prescribed by the Chair (which may be electronic) and as set forth in section 325-1.3 of this Subpart, or the form prescribed for outpatient hospital bills by the Commissioner of Health. (5) The Board will reject incomplete requests for an administrative award. When information regarding a workers' compensation claim that is included on a request for administrative award does not match the information in the Board's electronic case system, the request may be rejected by the Board and the provider will be directed to review such information with his or her patient. (6) Upon receipt by the Chair or his or her designee of a completed request for an administrative award, the request shall be examined to determine if it is in compliance with the requirements of this section. If the request is not in compliance with the requirements of this section, the request will be rejected by the Board with an explanation of why the request is being rejected. If the request is in full compliance with the requirement of this section, a notice of decision on the Chair prescribed form signed by the Chair or the Chair's designee will propose an administrative award for the Medical Care rendered not in excess of the fee schedule, if any, to the authorized physician, podiatrist, chiropractor, psychologist, occupational or physical therapist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital or other provider of Medical Care. The Chair prescribed form for the notice of decision will be sent to all parties of interest, notifying them of the proposed administrative award and the proposed filing date. The proposed filing date shall be at least 30 days after the date of the proposed administrative award. (7) Any party in interest may submit a written objection in the format prescribed by the Chair (which may be electronic) to the proposed award on or before the proposed filing date. All documents or other evidence supporting the objection shall be submitted together with the written objection. If there is no written objection received prior to the proposed filing date, the proposed award will become final on the proposed filing date. If an objection is received from any party before the proposed filing date, the objection shall be reviewed by the Chair or the Chair's designee, who shall make a decision on the request for an award based upon the documents and other evidence submitted. Upon review, a determination on reconsideration shall be sent to all parties in interest. (8) Interest on any administrative award made to a physician, self-employed occupational or physical therapist, podiatrist, chiropractor, psychologist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, or other provider of Medical Care, pursuant to this section shall be paid in accordance with the provisions of section 300.19 of this Title.

(1) Chair authorized physicians, podiatrists, chiropractors, psychologists, nurse practitioners, physician assistants, licensed clinical social workers, acupuncturists, occupational or physical therapists, and other legally permitted providers of Medical Care, or hospitals providing services to claimants who have timely submitted bills for payment to the insurance carrier or employer (or third-party administrator) and who have not been paid in full or in part or received notice in the format prescribed by the Chair (which may be electronic) for the purpose of advising of a valuation reason for non-payment within the time prescribed above, may apply to the Chair the prescribed format (which may be electronic) for an administrative award pursuant to the provisions of Workers' Compensation Law sections 13-g(1), 13-k(6), 13-l(6) and 13-m(7). Such request shall be submitted no earlier than 45 days from the date of the submission of the bill or 30 days from the date of the Workers' Compensation Law Judge or conciliation decision, or if appeal, Board Panel decision establishing the insurance carrier's or employer's (or third-party administrator's) liability for the bill, and within 120 days from the later of: (i) the date of receipt of notification of nonpayment; or (ii) the expiration of the time within which the insurance carrier or employer (or third-party administrator) is required to notify the physician, self-employed occupational or physical therapist, podiatrist, chiropractor, psychologist, or hospital of nonpayment.

(i) the date of receipt of notification of nonpayment; or

(ii) the expiration of the time within which the insurance carrier or employer (or third-party administrator) is required to notify the physician, self-employed occupational or physical therapist, podiatrist, chiropractor, psychologist, or hospital of nonpayment.

(2) Notwithstanding the foregoing, upon a written application of the physician, occupational or physical therapist, podiatrist, chiropractor, psychologist, nurse practitioners, physician assistants, licensed clinical social workers, acupuncturists, hospital, or other provider of Medical Care, the Chair may for good cause shown excuse a delay in the submission of the request for an administrative award

(3) (i) The Board will not accept any request for an administrative award until thirty days after all issues duly and timely raised by the employer or insurance carrier (or third-party administrator) with respect to its legal liability for payment and/or any Medical Treatment Guidelines objections set forth in paragraph (c)(7) of this section have been finally determined adversely to it. (ii) A provider may only submit one request for an administrative award for each date of service. A request for administrative award that includes a date of service that was included on a previously submitted request for administrative award will be rejected.

(i) The Board will not accept any request for an administrative award until thirty days after all issues duly and timely raised by the employer or insurance carrier (or third-party administrator) with respect to its legal liability for payment and/or any Medical Treatment Guidelines objections set forth in paragraph (c)(7) of this section have been finally determined adversely to it.

(ii) A provider may only submit one request for an administrative award for each date of service. A request for administrative award that includes a date of service that was included on a previously submitted request for administrative award will be rejected.

(4) All requests for administrative awards shall be submitted to the Chair or his or her designee in the format prescribed for such purpose and certifies the following information: (i) the bill was timely submitted to the employer or insurance carrier (or third-party administrator) and the bill was not returned; (ii) the employer or insurance carrier (or third-party administrator) did not submit payment within 45 days after the bill was submitted or within 30 days after all questions duly and timely raised related to the employer or insurance carrier (or third-party administrator)'s liability therefore was finally determined adversely to it; (iii) the employer or insurance carrier (or third-party administrator) did not raise valuation issues in the format prescribed by the Chair objecting to payment of the bill; (iv) the bill conforms to the fee schedule, if any, promulgated by the chair for treatment rendered; and (v) the bill was submitted in the format prescribed by the Chair (which may be electronic) and as set forth in section 325-1.3 of this Subpart, or the form prescribed for outpatient hospital bills by the Commissioner of Health.

(i) the bill was timely submitted to the employer or insurance carrier (or third-party administrator) and the bill was not returned;

(ii) the employer or insurance carrier (or third-party administrator) did not submit payment within 45 days after the bill was submitted or within 30 days after all questions duly and timely raised related to the employer or insurance carrier (or third-party administrator)'s liability therefore was finally determined adversely to it;

(iii) the employer or insurance carrier (or third-party administrator) did not raise valuation issues in the format prescribed by the Chair objecting to payment of the bill;

(iv) the bill conforms to the fee schedule, if any, promulgated by the chair for treatment rendered; and

(v) the bill was submitted in the format prescribed by the Chair (which may be electronic) and as set forth in section 325-1.3 of this Subpart, or the form prescribed for outpatient hospital bills by the Commissioner of Health.

(5) The Board will reject incomplete requests for an administrative award. When information regarding a workers' compensation claim that is included on a request for administrative award does not match the information in the Board's electronic case system, the request may be rejected by the Board and the provider will be directed to review such information with his or her patient.

(6) Upon receipt by the Chair or his or her designee of a completed request for an administrative award, the request shall be examined to determine if it is in compliance with the requirements of this section. If the request is not in compliance with the requirements of this section, the request will be rejected by the Board with an explanation of why the request is being rejected. If the request is in full compliance with the requirement of this section, a notice of decision on the Chair prescribed form signed by the Chair or the Chair's designee will propose an administrative award for the Medical Care rendered not in excess of the fee schedule, if any, to the authorized physician, podiatrist, chiropractor, psychologist, occupational or physical therapist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital or other provider of Medical Care. The Chair prescribed form for the notice of decision will be sent to all parties of interest, notifying them of the proposed administrative award and the proposed filing date. The proposed filing date shall be at least 30 days after the date of the proposed administrative award.

(7) Any party in interest may submit a written objection in the format prescribed by the Chair (which may be electronic) to the proposed award on or before the proposed filing date. All documents or other evidence supporting the objection shall be submitted together with the written objection. If there is no written objection received prior to the proposed filing date, the proposed award will become final on the proposed filing date. If an objection is received from any party before the proposed filing date, the objection shall be reviewed by the Chair or the Chair's designee, who shall make a decision on the request for an award based upon the documents and other evidence submitted. Upon review, a determination on reconsideration shall be sent to all parties in interest.

(8) Interest on any administrative award made to a physician, self-employed occupational or physical therapist, podiatrist, chiropractor, psychologist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, or other provider of Medical Care, pursuant to this section shall be paid in accordance with the provisions of section 300.19 of this Title.

(e) Arbitration award: a remedy for non-payment of bills when timely valuation objections are raised. (1) Chair authorized physicians, podiatrists, chiropractors, or psychologists, occupational or physical therapists, nurse practitioners, physician assistants, licensed clinical social workers, acupuncturists, hospitals or other legally permitted providers of Medical Care providing services to claimants who have timely submitted bills for payment to the employer or insurance carrier (or third-party administrator) in compliance with the provisions herein and have received a response in the format prescribed by the Chair (which may be electronic) from the employer or insurance carrier (or third-party administrator) advising of a valuation reason for non-payment of the bill in full or in part within the time prescribed in this section, may apply to the Chair for arbitration the format prescribed if the parties cannot agree as to the value of the services rendered. (2) Arbitration shall be requested solely at the option of the authorized physician, podiatrist, chiropractor, psychologist, occupational or physical therapist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital or other provider of Medical Care. (3) Notwithstanding the foregoing, upon a written application of the authorized physician, podiatrist, chiropractor, psychologist, occupational or physical therapist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital or other provider of Medical Care, the Chair may for good cause shown excuse a delay in the submission of the request for arbitration. (4) The Chair will not accept any request for an arbitration award until thirty days after all issues duly and timely raised by the employer or insurance carrier (or third-party administrator) with respect to its legal liability for payment and/or any Medical Treatment Guidelines objections set forth in paragraph (c)(7) of this section have been finally determined adversely to it.

(1) Chair authorized physicians, podiatrists, chiropractors, or psychologists, occupational or physical therapists, nurse practitioners, physician assistants, licensed clinical social workers, acupuncturists, hospitals or other legally permitted providers of Medical Care providing services to claimants who have timely submitted bills for payment to the employer or insurance carrier (or third-party administrator) in compliance with the provisions herein and have received a response in the format prescribed by the Chair (which may be electronic) from the employer or insurance carrier (or third-party administrator) advising of a valuation reason for non-payment of the bill in full or in part within the time prescribed in this section, may apply to the Chair for arbitration the format prescribed if the parties cannot agree as to the value of the services rendered.

(2) Arbitration shall be requested solely at the option of the authorized physician, podiatrist, chiropractor, psychologist, occupational or physical therapist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital or other provider of Medical Care.

(3) Notwithstanding the foregoing, upon a written application of the authorized physician, podiatrist, chiropractor, psychologist, occupational or physical therapist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital or other provider of Medical Care, the Chair may for good cause shown excuse a delay in the submission of the request for arbitration.

(4) The Chair will not accept any request for an arbitration award until thirty days after all issues duly and timely raised by the employer or insurance carrier (or third-party administrator) with respect to its legal liability for payment and/or any Medical Treatment Guidelines objections set forth in paragraph (c)(7) of this section have been finally determined adversely to it.

(f) Adjudication decision: a resolution for non-payment of bills when legal objections and medical treatment guidelines are raised. (1) If the employer or insurance carrier (or third-party administrator) objects to payment of all or part of the bill for Medical Care rendered for reasons concerning its legal liability for payment and/or the Medical Treatment Guidelines as set forth in paragraph (c)(7) of this section and raises legal and/or Medical Treatment Guidelines objections in the format prescribed by the Chair (which may be electronic) for such purpose as indicated herein, the objection will be reviewed by the Board and a decision rendered on the issue of legal liability and/or the Medical Treatment Guidelines objections. The decision shall be filed with the parties including the authorized physician, podiatrist, chiropractor, psychologist, occupational or physical therapist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital or other provider of Medical Care. (2) If legal liability and/or Medical Treatment Guidelines objection for the service is found in favor of the physician, podiatrist, chiropractor, psychologist, occupational or physical therapist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital or other provider of Medical Care, the employer, insurance carrier (or third-party administrator) shall pay the bill within 30 days from the filing of the proposed decision or Notice of Decision unless the employer or insurance carrier (or third-party administrator) timely submitted a valuation objection simultaneously with its legal objection(s) to the medical provider's bill. (3) If the employer or insurance carrier (or third-party administrator) files an application for review pursuant to Workers' Compensation Law section 23 from the Notice of Decision finding legal liability and/or Medical Treatment Guidelines objection in favor of the physician, podiatrist, chiropractor, psychologist, occupational or physical therapist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital or other provider of Medical Care, the employer or insurance carrier (or third-party administrator) may withhold payment of the bills up to the amount in dispute until a Workers' Compensation Law Judge or conciliation decision, or if appealed, a Board Panel decision is rendered by the Board. If a Workers' Compensation Law Judge or conciliation decision, or if appealed, a Board Panel decision is filed finding legal liability and/or Medical Treatment Guidelines objection in favor of the physician, podiatrist, chiropractor, psychologist, occupational or physical therapist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital or other provider of Medical Care, the employer or insurance carrier (or third-party administrator) shall pay the bill within 30 days from the filing of the Workers' Compensation Law Judge or conciliation decision, or if appealed, Board Panel decision unless the employer or insurance carrier (or third-party administrator) timely submitted a valuation objection simultaneously with its legal objection(s) to the medical provider's bill . A subsequent application to the Full Board, except for review by the Full Board of a Board Panel decision which one member dissented from, or to the Appellate Division of the Supreme Court, Third Department, or to the Court of Appeals on the issue of legal liability/or Medical Treatment Guidelines objection shall not operate as a stay of the payment of the bills for medical or hospital services.

(1) If the employer or insurance carrier (or third-party administrator) objects to payment of all or part of the bill for Medical Care rendered for reasons concerning its legal liability for payment and/or the Medical Treatment Guidelines as set forth in paragraph (c)(7) of this section and raises legal and/or Medical Treatment Guidelines objections in the format prescribed by the Chair (which may be electronic) for such purpose as indicated herein, the objection will be reviewed by the Board and a decision rendered on the issue of legal liability and/or the Medical Treatment Guidelines objections. The decision shall be filed with the parties including the authorized physician, podiatrist, chiropractor, psychologist, occupational or physical therapist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital or other provider of Medical Care.

(2) If legal liability and/or Medical Treatment Guidelines objection for the service is found in favor of the physician, podiatrist, chiropractor, psychologist, occupational or physical therapist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital or other provider of Medical Care, the employer, insurance carrier (or third-party administrator) shall pay the bill within 30 days from the filing of the proposed decision or Notice of Decision unless the employer or insurance carrier (or third-party administrator) timely submitted a valuation objection simultaneously with its legal objection(s) to the medical provider's bill.

(3) If the employer or insurance carrier (or third-party administrator) files an application for review pursuant to Workers' Compensation Law section 23 from the Notice of Decision finding legal liability and/or Medical Treatment Guidelines objection in favor of the physician, podiatrist, chiropractor, psychologist, occupational or physical therapist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital or other provider of Medical Care, the employer or insurance carrier (or third-party administrator) may withhold payment of the bills up to the amount in dispute until a Workers' Compensation Law Judge or conciliation decision, or if appealed, a Board Panel decision is rendered by the Board. If a Workers' Compensation Law Judge or conciliation decision, or if appealed, a Board Panel decision is filed finding legal liability and/or Medical Treatment Guidelines objection in favor of the physician, podiatrist, chiropractor, psychologist, occupational or physical therapist, nurse practitioner, physician assistant, licensed clinical social worker, acupuncturist, hospital or other provider of Medical Care, the employer or insurance carrier (or third-party administrator) shall pay the bill within 30 days from the filing of the Workers' Compensation Law Judge or conciliation decision, or if appealed, Board Panel decision unless the employer or insurance carrier (or third-party administrator) timely submitted a valuation objection simultaneously with its legal objection(s) to the medical provider's bill . A subsequent application to the Full Board, except for review by the Full Board of a Board Panel decision which one member dissented from, or to the Appellate Division of the Supreme Court, Third Department, or to the Court of Appeals on the issue of legal liability/or Medical Treatment Guidelines objection shall not operate as a stay of the payment of the bills for medical or hospital services.

(g) Effective date. This regulation shall be effective on January 1, 2020.

Aggregated from public-domain New York law; last amended effective 2023-07-11.

(a) Definitions. Telehealth shall mean treatment by physicians, podiatrists, psychologists, nurse practitioners, physician assistants, and licensed clinical social workers authorized by the Chair to provide treatment and care under the Workers' Compensation Law (hereinafter "Authorized Medical Provider") using two-way audio and visual electronic communication, or audio only. (1) When rendering medical treatment or care via telehealth, an Authorized Medical Provider must be available for an in-person clinical encounter with the claimant should such in-person encounter be medically necessary. This means the Authorized Medical Provider must be able to meet the claimant at the Authorized Medical Provider's office within a reasonable travel time and distance from the claimant's residence. (2) Telehealth must be used in accordance with this section and any applicable New York State Medical Treatment Guideline incorporated by reference under section 324.2 of this Title. (3) Authorized Medical Providers shall bill using the applicable Evaluation and Management code 99212 using Modifier 95 when services are rendered by telehealth using two-way audio and visual communication. When services are rendered by audio only in accordance with section 325-1.8 of this Title, the Authorized Medical Provider shall use Modifier 93. Place of service Code 10 shall be used when services are rendered while patient is in their home. Place of service code 02 shall be used when services are rendered while patient is in a healthcare setting that is not their home. When completing the report of treatment, the Authorized Medical Provider shall identify the address from which they rendered Medical Care via telehealth as the Authorized Medical Provider's business address. Notwithstanding the codes listed in this paragraph, appropriate telehealth codes as may appear in any future versions of the Official New York Workers' Compensation Medical Fee Schedule as incorporated by reference in section 329-1.3 of this Title may be used and will have the same effective date as the effective date of the future version of the Official New York Workers' Compensation Medical Fee Schedule.

(1) When rendering medical treatment or care via telehealth, an Authorized Medical Provider must be available for an in-person clinical encounter with the claimant should such in-person encounter be medically necessary. This means the Authorized Medical Provider must be able to meet the claimant at the Authorized Medical Provider's office within a reasonable travel time and distance from the claimant's residence.

(2) Telehealth must be used in accordance with this section and any applicable New York State Medical Treatment Guideline incorporated by reference under section 324.2 of this Title.

(3) Authorized Medical Providers shall bill using the applicable Evaluation and Management code 99212 using Modifier 95 when services are rendered by telehealth using two-way audio and visual communication. When services are rendered by audio only in accordance with section 325-1.8 of this Title, the Authorized Medical Provider shall use Modifier 93. Place of service Code 10 shall be used when services are rendered while patient is in their home. Place of service code 02 shall be used when services are rendered while patient is in a healthcare setting that is not their home. When completing the report of treatment, the Authorized Medical Provider shall identify the address from which they rendered Medical Care via telehealth as the Authorized Medical Provider's business address. Notwithstanding the codes listed in this paragraph, appropriate telehealth codes as may appear in any future versions of the Official New York Workers' Compensation Medical Fee Schedule as incorporated by reference in section 329-1.3 of this Title may be used and will have the same effective date as the effective date of the future version of the Official New York Workers' Compensation Medical Fee Schedule.

(b) Treatment via telehealth.(1) Treatment by Board-authorized physicians, podiatrists, nurse practitioners, and physician assistants under the Official New York Workers' Compensation Medical Fee Schedule as incorporated by reference in section 329-1.3 of this Title or the Official New York Workers' Compensation Podiatry Fee Schedule as incorporated by reference in section 343.2 of this Title may be rendered by telehealth following an initial in-person clinical encounter when medically appropriate and subject to the following restrictions: (i) Acute and Subacute phases of injury or illness. Within the first three months following the date of injury or illness, use of telehealth shall be at the clinical discretion of the treating physician, podiatrist, nurse practitioner, or physician assistant, except that at least every third clinical encounter must be an in-person assessment by the treating physician, podiatrist, nurse practitioner, or physician assistant. (ii) Chronic phase of injury or illness. When more than three months has passed from the date of injury or illness, use of telehealth shall be at the clinical discretion of the treating physician, podiatrist, nurse practitioner, or physician assistant, except that there must be an in-person assessment by the treating physician, podiatrist, nurse practitioner, or physician assistant, no less than every three months unless or until such provider has determined the patient has reached Maximum Medical Improvement (MMI) and has stated that the impairment or disability status is permanent and unlikely to change. (iii) Injury or illness at MMI. When the claimant is in the chronic phase of injury or illness as defined in subparagraph (ii) of this paragraph and the treating physician, podiatrist, nurse practitioner, or physician assistant's opinion is that the claimant has reached MMI and the patient's impairment or disability status is permanent and unlikely to change, use of telehealth shall be at the discretion of the treating physician, podiatrist, nurse practitioner, or physician assistant, except that there must be an in-person assessment by such provider at least annually. (2) Treatment by Board-authorized psychologists and licensed clinical social workers under the Official New York Workers' Compensation Behavioral Health Fee Schedule as incorporated by reference in section 333.2 of this Title may be rendered by telehealth when medically appropriate and in accordance with applicable Medical Treatment Guidelines using the following codes: (i) New patient Evaluation and Management codes 99201-99204. (ii) Psychotherapy combination codes and crisis codes: 90832-90834, 90836-90840, 90853. (iii) Group therapy: 90853. The number of patients participating in a group therapy session via telehealth shall not exceed the number that would otherwise be permissible if the group therapy session had been held in person and does not require that every participant in the group therapy session be a workers' compensation claimant. (iv) Remote behavioral health visits should be limited to those situations when there is no benefit to in-person services (versus remote services) or when an in-person office visit poses an undue risk or hardship on the patient. The reason for the use of a remote telehealth visit should be documented with each use of a telehealth visit. (3) Treatment rendered by Board-authorized chiropractors, acupuncturists, physical therapists, and occupational therapists under the Official New York Workers' Compensation Chiropractic Fee Schedule as incorporated by reference in section 348.2 of this Title and the Official New York Workers' Compensation Acupuncture and Physical Therapy and Occupational Therapy Fee Schedule as incorporated by reference in section 329-4.2 of this Title may not be rendered via telehealth.

(1) Treatment by Board-authorized physicians, podiatrists, nurse practitioners, and physician assistants under the Official New York Workers' Compensation Medical Fee Schedule as incorporated by reference in section 329-1.3 of this Title or the Official New York Workers' Compensation Podiatry Fee Schedule as incorporated by reference in section 343.2 of this Title may be rendered by telehealth following an initial in-person clinical encounter when medically appropriate and subject to the following restrictions: (i) Acute and Subacute phases of injury or illness. Within the first three months following the date of injury or illness, use of telehealth shall be at the clinical discretion of the treating physician, podiatrist, nurse practitioner, or physician assistant, except that at least every third clinical encounter must be an in-person assessment by the treating physician, podiatrist, nurse practitioner, or physician assistant. (ii) Chronic phase of injury or illness. When more than three months has passed from the date of injury or illness, use of telehealth shall be at the clinical discretion of the treating physician, podiatrist, nurse practitioner, or physician assistant, except that there must be an in-person assessment by the treating physician, podiatrist, nurse practitioner, or physician assistant, no less than every three months unless or until such provider has determined the patient has reached Maximum Medical Improvement (MMI) and has stated that the impairment or disability status is permanent and unlikely to change. (iii) Injury or illness at MMI. When the claimant is in the chronic phase of injury or illness as defined in subparagraph (ii) of this paragraph and the treating physician, podiatrist, nurse practitioner, or physician assistant's opinion is that the claimant has reached MMI and the patient's impairment or disability status is permanent and unlikely to change, use of telehealth shall be at the discretion of the treating physician, podiatrist, nurse practitioner, or physician assistant, except that there must be an in-person assessment by such provider at least annually.

(i) Acute and Subacute phases of injury or illness. Within the first three months following the date of injury or illness, use of telehealth shall be at the clinical discretion of the treating physician, podiatrist, nurse practitioner, or physician assistant, except that at least every third clinical encounter must be an in-person assessment by the treating physician, podiatrist, nurse practitioner, or physician assistant.

(ii) Chronic phase of injury or illness. When more than three months has passed from the date of injury or illness, use of telehealth shall be at the clinical discretion of the treating physician, podiatrist, nurse practitioner, or physician assistant, except that there must be an in-person assessment by the treating physician, podiatrist, nurse practitioner, or physician assistant, no less than every three months unless or until such provider has determined the patient has reached Maximum Medical Improvement (MMI) and has stated that the impairment or disability status is permanent and unlikely to change.

(iii) Injury or illness at MMI. When the claimant is in the chronic phase of injury or illness as defined in subparagraph (ii) of this paragraph and the treating physician, podiatrist, nurse practitioner, or physician assistant's opinion is that the claimant has reached MMI and the patient's impairment or disability status is permanent and unlikely to change, use of telehealth shall be at the discretion of the treating physician, podiatrist, nurse practitioner, or physician assistant, except that there must be an in-person assessment by such provider at least annually.

(2) Treatment by Board-authorized psychologists and licensed clinical social workers under the Official New York Workers' Compensation Behavioral Health Fee Schedule as incorporated by reference in section 333.2 of this Title may be rendered by telehealth when medically appropriate and in accordance with applicable Medical Treatment Guidelines using the following codes: (i) New patient Evaluation and Management codes 99201-99204. (ii) Psychotherapy combination codes and crisis codes: 90832-90834, 90836-90840, 90853. (iii) Group therapy: 90853. The number of patients participating in a group therapy session via telehealth shall not exceed the number that would otherwise be permissible if the group therapy session had been held in person and does not require that every participant in the group therapy session be a workers' compensation claimant. (iv) Remote behavioral health visits should be limited to those situations when there is no benefit to in-person services (versus remote services) or when an in-person office visit poses an undue risk or hardship on the patient. The reason for the use of a remote telehealth visit should be documented with each use of a telehealth visit.

(i) New patient Evaluation and Management codes 99201-99204.

(ii) Psychotherapy combination codes and crisis codes: 90832-90834, 90836-90840, 90853.

(iii) Group therapy: 90853. The number of patients participating in a group therapy session via telehealth shall not exceed the number that would otherwise be permissible if the group therapy session had been held in person and does not require that every participant in the group therapy session be a workers' compensation claimant.

(iv) Remote behavioral health visits should be limited to those situations when there is no benefit to in-person services (versus remote services) or when an in-person office visit poses an undue risk or hardship on the patient. The reason for the use of a remote telehealth visit should be documented with each use of a telehealth visit.

(3) Treatment rendered by Board-authorized chiropractors, acupuncturists, physical therapists, and occupational therapists under the Official New York Workers' Compensation Chiropractic Fee Schedule as incorporated by reference in section 348.2 of this Title and the Official New York Workers' Compensation Acupuncture and Physical Therapy and Occupational Therapy Fee Schedule as incorporated by reference in section 329-4.2 of this Title may not be rendered via telehealth.

(c) Medically appropriate for telehealth means that an in-person physical examination of the claimant is not needed in order to assess the claimant's clinical status, need for further diagnostic testing, appropriate treatment, or the determination of causal relationship or level of disability. The terms and factors referenced in this subdivision use medical terms of art in the context of best medical practice and are parameters by which providers should prospectively determine whether an in-person physical examination is necessary and should not be the basis of a denial by carriers, self-insured employers, or third-party administrators. (1) Factors where an in-person physical examination may not be necessary and therefore treatment by telehealth may be medically appropriate include but are not limited to: (i) Management of chronic conditions where the Authorized Medical Provider has previously conducted a medically appropriate and comprehensive in-person assessment of the patient and condition and is fully familiar with the applicable medical history. (ii) Discussion of test results. (iii) Counseling about diagnostic and therapeutic options. (iv) Dermatology, for visits not requiring palpation or biopsy of a lesion to accurately diagnose or treat the condition. (v) Prescriptions for medication, subject to the limitations in paragraph (2) of this subdivision. (vi) Nutrition counseling. (vii) Mental health counseling, for which in-person assessment of body movements, postures, and other nonverbal cues is not needed for accurate diagnosis, treatment, or interim assessment of a condition or the potential adverse side-effects of a medication. (viii) Other clinical scenarios as may be prescribed in Medical Treatment Guidelines or other related Board communications. (2) Factors that indicate an in-person physical examination is necessary and treatment via telehealth is not medically appropriate include but are not limited to: (i) Health concerns that require a procedure. (ii) Abdominal pain, chest pain, clinically altered mental status, any situation in which it appears the claimant may pose a risk to themselves or others, severe headache, signs or symptoms of a stroke, or any other clinical presentation that is generally accepted as requiring in-person, emergent or urgent medical assessment, and for which in-person resources (e.g. regional hospital emergency departments or free-standing urgent care centers, as may be clinically appropriate) are readily available. (iii) Eye or vision complaints. (iv) Highly nuanced or multiple complex health concerns requiring an in-person examination to assess subtle interactions between co-morbidities or medications. (v) Any situation in which an in-person physical exam might reasonably impact the accuracy, quality, or certainty of the Authorized Medical Provider's assessment, treatment, or recommendations. (vi) Any situation where an in-person physical examination is needed to assess disability or range of motion, including but not limited to strength testing, formal range of motion testing, assessment of joint stability, nuanced orthopedic and/or neurologic testing, spirometry or pulmonary function testing, or exercise tolerance testing. (vii) Any physical therapy, occupational therapy, or chiropractic services utilizing physical modalities other than instruction on range of motion or strengthening exercises. (viii) Any other clinical scenarios as may be prescribed in Medical Treatment Guidelines or other related Board communications. (ix) Assessment of causal relationship for an injury or illness unless an in-person physical examination is not necessary to make the determination of causal relationship, in which case the Authorized Medical Provider must specifically articulate in the medical record why an in-person examination was not necessary in order to make a determination of causal relationship. (3) Notwithstanding any of the factors listed in paragraph (1) of this subdivision, the following procedures or situations are not medically appropriate for telehealth:(i) Urine drug testing. (ii) The initial prescription of long-term medications or follow-up monitoring of those medications without periodic in-person evaluation. (iii) Where the nature of treatment set forth in the Medical Treatment Guidelines necessitates an in-person examination. (iv) Assessment of permanent disability. (v) Any other clinical scenarios as may be outlined by the Board in Medical Treatment Guidelines or other related Board communications. (vi) The patient lacks suitable technology or equipment necessary to conduct the telehealth visit. (vii) The patient has physical and/or cognitive challenges that would be a barrier to an effective telehealth visit (without the assistance of another individual). (viii) The patient has expressed a preference for an in-person visit, as well as a willingness and capability to travel to an in-person visit.

(1) Factors where an in-person physical examination may not be necessary and therefore treatment by telehealth may be medically appropriate include but are not limited to: (i) Management of chronic conditions where the Authorized Medical Provider has previously conducted a medically appropriate and comprehensive in-person assessment of the patient and condition and is fully familiar with the applicable medical history. (ii) Discussion of test results. (iii) Counseling about diagnostic and therapeutic options. (iv) Dermatology, for visits not requiring palpation or biopsy of a lesion to accurately diagnose or treat the condition. (v) Prescriptions for medication, subject to the limitations in paragraph (2) of this subdivision. (vi) Nutrition counseling. (vii) Mental health counseling, for which in-person assessment of body movements, postures, and other nonverbal cues is not needed for accurate diagnosis, treatment, or interim assessment of a condition or the potential adverse side-effects of a medication. (viii) Other clinical scenarios as may be prescribed in Medical Treatment Guidelines or other related Board communications.

(i) Management of chronic conditions where the Authorized Medical Provider has previously conducted a medically appropriate and comprehensive in-person assessment of the patient and condition and is fully familiar with the applicable medical history.

(ii) Discussion of test results.

(iii) Counseling about diagnostic and therapeutic options.

(iv) Dermatology, for visits not requiring palpation or biopsy of a lesion to accurately diagnose or treat the condition.

(v) Prescriptions for medication, subject to the limitations in paragraph (2) of this subdivision.

(vi) Nutrition counseling.

(vii) Mental health counseling, for which in-person assessment of body movements, postures, and other nonverbal cues is not needed for accurate diagnosis, treatment, or interim assessment of a condition or the potential adverse side-effects of a medication.

(viii) Other clinical scenarios as may be prescribed in Medical Treatment Guidelines or other related Board communications.

(2) Factors that indicate an in-person physical examination is necessary and treatment via telehealth is not medically appropriate include but are not limited to: (i) Health concerns that require a procedure. (ii) Abdominal pain, chest pain, clinically altered mental status, any situation in which it appears the claimant may pose a risk to themselves or others, severe headache, signs or symptoms of a stroke, or any other clinical presentation that is generally accepted as requiring in-person, emergent or urgent medical assessment, and for which in-person resources (e.g. regional hospital emergency departments or free-standing urgent care centers, as may be clinically appropriate) are readily available. (iii) Eye or vision complaints. (iv) Highly nuanced or multiple complex health concerns requiring an in-person examination to assess subtle interactions between co-morbidities or medications. (v) Any situation in which an in-person physical exam might reasonably impact the accuracy, quality, or certainty of the Authorized Medical Provider's assessment, treatment, or recommendations. (vi) Any situation where an in-person physical examination is needed to assess disability or range of motion, including but not limited to strength testing, formal range of motion testing, assessment of joint stability, nuanced orthopedic and/or neurologic testing, spirometry or pulmonary function testing, or exercise tolerance testing. (vii) Any physical therapy, occupational therapy, or chiropractic services utilizing physical modalities other than instruction on range of motion or strengthening exercises. (viii) Any other clinical scenarios as may be prescribed in Medical Treatment Guidelines or other related Board communications. (ix) Assessment of causal relationship for an injury or illness unless an in-person physical examination is not necessary to make the determination of causal relationship, in which case the Authorized Medical Provider must specifically articulate in the medical record why an in-person examination was not necessary in order to make a determination of causal relationship.

(i) Health concerns that require a procedure.

(ii) Abdominal pain, chest pain, clinically altered mental status, any situation in which it appears the claimant may pose a risk to themselves or others, severe headache, signs or symptoms of a stroke, or any other clinical presentation that is generally accepted as requiring in-person, emergent or urgent medical assessment, and for which in-person resources (e.g. regional hospital emergency departments or free-standing urgent care centers, as may be clinically appropriate) are readily available.

(iii) Eye or vision complaints.

(iv) Highly nuanced or multiple complex health concerns requiring an in-person examination to assess subtle interactions between co-morbidities or medications.

(v) Any situation in which an in-person physical exam might reasonably impact the accuracy, quality, or certainty of the Authorized Medical Provider's assessment, treatment, or recommendations.

(vi) Any situation where an in-person physical examination is needed to assess disability or range of motion, including but not limited to strength testing, formal range of motion testing, assessment of joint stability, nuanced orthopedic and/or neurologic testing, spirometry or pulmonary function testing, or exercise tolerance testing.

(vii) Any physical therapy, occupational therapy, or chiropractic services utilizing physical modalities other than instruction on range of motion or strengthening exercises.

(viii) Any other clinical scenarios as may be prescribed in Medical Treatment Guidelines or other related Board communications.

(ix) Assessment of causal relationship for an injury or illness unless an in-person physical examination is not necessary to make the determination of causal relationship, in which case the Authorized Medical Provider must specifically articulate in the medical record why an in-person examination was not necessary in order to make a determination of causal relationship.

(3) Notwithstanding any of the factors listed in paragraph (1) of this subdivision, the following procedures or situations are not medically appropriate for telehealth:(i) Urine drug testing. (ii) The initial prescription of long-term medications or follow-up monitoring of those medications without periodic in-person evaluation. (iii) Where the nature of treatment set forth in the Medical Treatment Guidelines necessitates an in-person examination. (iv) Assessment of permanent disability. (v) Any other clinical scenarios as may be outlined by the Board in Medical Treatment Guidelines or other related Board communications. (vi) The patient lacks suitable technology or equipment necessary to conduct the telehealth visit. (vii) The patient has physical and/or cognitive challenges that would be a barrier to an effective telehealth visit (without the assistance of another individual). (viii) The patient has expressed a preference for an in-person visit, as well as a willingness and capability to travel to an in-person visit.

(i) Urine drug testing.

(ii) The initial prescription of long-term medications or follow-up monitoring of those medications without periodic in-person evaluation.

(iii) Where the nature of treatment set forth in the Medical Treatment Guidelines necessitates an in-person examination.

(iv) Assessment of permanent disability.

(v) Any other clinical scenarios as may be outlined by the Board in Medical Treatment Guidelines or other related Board communications.

(vi) The patient lacks suitable technology or equipment necessary to conduct the telehealth visit.

(vii) The patient has physical and/or cognitive challenges that would be a barrier to an effective telehealth visit (without the assistance of another individual).

(viii) The patient has expressed a preference for an in-person visit, as well as a willingness and capability to travel to an in-person visit.

(d) Independent Medical Examinations (IMEs) are not treatment under the Workers' Compensation Law. Accordingly, IMEs conducted pursuant to section 300.2 of this Title and section 137 of the Workers' Compensation Law, may be conducted via telehealth when all parties of interest consent to such telehealth examination, and the independent medical examiner is not offering an opinion on permanent impairment.