For physicians, there’s no shortage of paperwork to tackle when treating an injured worker. But in New York State, many physicians are submitting unnecessary Prior Authorization Requests (PARs).

Physicians submit PARs to obtain permission from the workers’ comp claims administrator to furnish treatment. In some cases, PARs are necessary to ensure reimbursement.

However, prior authorization is not required when the treatment adheres to the state’s Medical Treatment Guidelines (MTGs).

The New York Workers’ Compensation Board (WCB) assures physicians that (subject to correct application of the guidelines) treatments listed in the MTGs are presumed authorized and eligible for compensation. 

Accordingly, as long as the physician accurately references the MTG in the supporting documentation submitted with the bill, they can skip the hassle of submitting a PAR.

For a complete list of MTGs, providers can refer to the table below.

The New York WCB designed the MTGs to establish a standard of care for treating work-related injuries. Remember, to treat injuries for which there’s an applicable MTG, providers must adhere to the MTG.

The table below lists all currently applicable MTGs, effective from May 2, 2022. The list links to the relevant WCB publications, including treatment approaches and specific exceptions to pre-authorization.

New York State Medical Treatment Guidelines

Payment Requirements, Objections, and Deadlines

At a recent WCB conference, presenters noted that in many cases, physicians choose to submit PARs even when the applicable MTGs support the physician’s recommended treatment, in order to avoid payment denials based on lack of prior authorization.

Physicians should note that such payment denials are invalid, according to the WCB.

Per New York State Codes, Rules, and Regulations Section 325-1.25, the claims administrator must pay for all properly documented, MTG-supported care (regardless of prior authorization) or file a formal objection within 45 days.

As the required WCB form for objecting to a provider’s bill instructs, failure to pay undisputed charges may result in interest charges. If the claims administrator fails to timely pay or object, the provider may pursue reimbursement by submitting a Request for Decision on Unpaid Medical Bill(s) (Form HP-1.0) through the WCB’s OnBoard portal.

NY WCB Offers Provider Resources

The WCB offers loads of helpful information to guide providers in correctly applying the MTG. Visit the Frequently Asked Questions page (shown below) on the WCB website to find guidance and training.

Have more questions? The WCB invites providers to reach out directly by calling their customer service number: (877) 632-4996. The WCB is available Monday through Friday from 8:30 AM to 4:30 PM EST.

daisyBill is here to help New York providers treat injured workers—and get paid quickly and correctly. Client or not, you can use the pink chat icon in the bottom right of this screen to reach our experts, or email us at info@daisybill.com.

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