State Of New York Workers' Compensation Board - Attending Doctor'S Request For Medical Authorization Determination Page 2
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212 NYCRR 325-1.4 Authorization for Special Services
(a)(1) When it is necessary for the attending physician to engage the services of a specialist, consultant, or a surgeon,
or to provide for X-ray examinations or occupational therapy or physical therapy or special diagnostic laboratory tests
costing more than $500, he or she must request and secure authorization from the employer or insurance carrier or the
chair, by setting forth the medical necessity of the special services required.
For example, when the total fees for
occupational or physical therapy treatment approach the sum of $500, the physician shall file an additional C-4 report and
request authorization as prescribed in subdivision (5) of section 13-a of the Workers' Compensation Law.
(2) This section also applies to hospitals, specialists, consultants and surgeons, who are actually engaged to perform
such services.
(3) Such request for authorization should be by telephone to the employer or carrier and later confirmed by letter.
(4) In order to process such requests expeditiously and within the time limits specified hereunder, the insurance carrier
shall designate a qualified employee in its office, and the self-insured employer shall designate a qualified employee in its
office or an authorized employee of its licensed representative, to receive and act upon such requests. To assure
compliance within the time limits prescribed, qualified persons shall be specially designated, within each office of the
Workers' Compensation Board, to deal with complaints relative to such authorizations.
(5) In response to requests for authorization, the self-insured employer or insurance carrier may have the patient
examined within four business days if patient is hospitalized or thirty days if patient is not hospitalized, by an appropriate
medical board-certified specialist who is also authorized in such specialty, by the chair, to treat workers' compensation
claimants. If such specialist is not available, consultation may be rendered by an authorized physician who is acceptable to
both the self-insured employer or insurance carrier and the physician requesting authorization, or in the event the parties
cannot agree, a physician may be selected by the chair.
(6) The self-insured employer or insurance carrier shall grant or deny the requested authorization within four working
days if the claimant is hospitalized, or within thirty days if the claimant is not hospitalized, by orally notifying the physician or
hospital of its action. It shall confirm such action in writing by sending a notice to the physician, claimant's attorney or
licensed representative and/or hospital within five days after the examination of the claimant when the four-day provision
applies. When the 30 day provision applies, the written confirmation shall be mailed within such period. Written notice of
denial must be based on a conflicting second opinion rendered by a physician authorized to treat workers' compensation
claimants. Nothing herein shall relieve the carrier from complying with the provisions of 12 NYCRR 300.23.
(7) If such authorization or denial is not forthcoming within four working days if patient is hospitalized, the chair may
issue an order, after investigation, authorizing the special services, on the ground that such authorization has been
unreasonably withheld and the employer or carrier shall be liable for the payment for such special services and investigation.
If such authorization or denial is not forthcoming within thirty calendar days if patient is not hospitalized, such request shall
be deemed authorized and the employer or carrier shall be liable for payment for such special services. The chair may
issue an order stating that such request is deemed authorized or requiring the employer or carrier to provide written
authorization, if such documentation is required by the claimant to secure necessary medical treatment.
(8) Such authorization is not required in an emergency under the provisions of subdivision (5) of section 13-a of the
Workers' Compensation Law.
(b) Authorization for medical care when the right to compensation is controverted.
(1) Whenever medical care or special services are required in cases when the right to compensation is controverted or
the time to controvert has not expired, the attending physician or the hospitals, specialists, consultants and surgeons
engaged to perform such services shall request authorization from the employer or insurance carrier who would become
responsible in the event the claim is adjudicated compensable; and all provisions of subdivision (a) of this section are
applicable to such requests.
(2) The authorization herein referred to, if granted by the self-insured employer or insurance carrier, 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 shall
not be responsible for the payment of such services until the question of compensability is resolved.
HIPAA NOTICE - In order to adjudicate a workers' compensation claim, WCL13-a(4)(a) and 12 NYCRR 325-1.3 require health
care providers to regularly file medical reports of treatment with the Board and the carrier or employer. Pursuant to 45 CFR
164.512 these legally required medical reports are exempt from HIPAA's restrictions on disclosure of health information.
WORKERS' COMPENSATION BOARD DISTRICT OFFICES
100 Broadway
State Office Building
Statler Towers
DOWNSTATE CENTRALIZED MAILING
Menands
44 Hawley Street
130 Main Street W.
935 James St.
107 Delaware Ave.
(for New York City, Hempstead, Hauppauge & Peekskill Districts)
ALBANY 12241
BINGHAMTON 13901
ROCHESTER 14614
SYRACUSE 13203
BUFFALO 14202
PO Box 5205 Binghamton, NY 13902-5205
(866) 750-5157
(866) 802-3604
(866) 211-0644
(866) 802-3730
(866) 211-0645
NYC (800)877-1373/Hemp. (866)805-3630/Haup. (866)681-5354/Peek. (866)746-0552
MD-1 (12-03) Reverse
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