The Latest New Laws In Workers Compensation

In May 2022, the New York Workers Compensation Board implemented a new OnBoard system named the Prior Authorization Request (“PAR”) intended to streamline the process for medical treatment requests. This new system incorporates involvement from insurance carrier physicians (“Level 2 Reviewers”) and the Board’s Medical Director’s Office (“MDO”). All PAR documents are saved in the Board’s electronic case folder (“eCase”).

The PAR process is intended to replace existing forms (i.e., MG-2, C-4Auth) and reduce the extensive paper filings. Previously, a treating doctor would request physical therapy on an MG-2 form. The insurance company would respond by granting the MG-2, denying the MG-2, or requesting an independent medical exam (“IME”) that ultimately grant or deny the treatment. If the treatment was denied, the injured workers’ attorney could request a hearing or decision. Each of these processes would require printing, signing, and serving papers on opposing parties. With PAR, the process is completed electronically with electronic service on the opposing parties.

Since its implementation in May 2022, several procedural questions have arisen from providers and attorneys as to when and how to become involved. There are many unknowns as stakeholders work their way through this newly created way of obtaining medical authorizations and treatments for injured workers. Below is an outline of the new PAR system and how to maneuver your way through this new complex system.

Seven types of requests are submitted through OnBoard as PAR requests. There are two new types of requests included in the PAR system.

MTG Confirmation (MG-1)
MTG Variance (MG-2)
MTG Special Services (C-4Auth)
Non-MTG over $1,000 (C-4Auth)
Non-MTG under $1,000 (new)
Medication (Drug Formulary)
Durable Medical Equipment (“DME”) (new)

In each case, other than medications, healthcare providers must submit the request with supporting documentation to the last claims contact person who filed the most recent FROI/SROI.

The PAR process utilizes levels. Level 1 review frequently comes from the claims’ administrator or adjuster. Level 2 review is provided by the carrier’s physician (aka “Level 2 reviewer”). Level 3 review occurs when the request is reviewed by the MDO. The carrier’s physician and involvement by MDO are new roles exclusive to the PAR process. For example, when a request is granted in part or denied for medical reasons, then Level 2 review from the insurance company’s physician is automatic. If a case was controverted, disallowed, cancelled, or the medical was closed with a Section 32 agreement, then carrier physician review is not required.

For the purposes of this article, denials will include requests that are granted, in part. A provider and claimant can always move forward with any request that was granted, in part, or alternatively, pursue approval of the denied portion of the request.

1. MTG Confirmation (MG-1)

An MTG Confirmation is consistent with the Board’s MG-1 Form. The request confirms consistency with the MTGs. The purpose is to ensure a provider of approval prior to rendering treatment.

When a carrier fails to respond to a PAR request within 8 business days, the request is deemed approved and Board will issue an Order of the Chair.

Decision	Reason	Action
Granted	N/A	None
Denied without carrier physician review	N/A	Claimant files RFA-1, citing denial as “factually inaccurate”
Denied with carrier physician review	Does not confirm consistency of MTGs	Physician files MG-2 Variance request or Physician requests review within 10 calendar days
Denied	Administrative or No Jurisdiction	Claimant files an RFA-1, checking box “i”, first sub-box

2. MTG Variance (MG-2)

An MTG Variance is consistent with an MG-2 Form. The MTG Variance requests a test, treatment, or procedure not recommended by the MTGs, contending that it is appropriate and medically necessary.

Review can be performed by a carrier’s physician, IME, or record review. Review is not required when:

Treatment was already rendered;
A substantially similar or duplicate request is pending and has not been denied;
A substantially similar or duplicate request was denied and there is not new information to help support the request; or
The case was controverted, disallowed, cancelled, or the medical was closed with a Section 32 agreement.

A carrier must respond within 15 calendar days of the request unless the carrier decides to request an IME or record review. When requesting an IME or record review, the carrier must notify the other parties within five business days and respond within 30 calendar days.

Decision	Reason	Action
Granted	N/A	None
Denied without review	N/A	Claimant files RFA-1, citing denial as “factually inaccurate”
Denied even though medically necessary	N/A	Must be reviewed by carrier’s physician, IME, or record review.
Denied by Claims’Administrator	Medical Reason.	Automatically escalated to the carrier’s physician.
Denied	Burden of Proof	Automatically escalated to the carrier’s physician as medical rationale is required.
Denied	Controverted Case	IME deemed waived if the case is later established unless the carrier presents a contrary medical opinion at the time of the denial.
IME denies	Based upon IME report.	Claimant files RFA-1 or Claimant’s physician requests review by MDO
MDO denies	N/A	Claimant files RFA-1
Denied	Administrative or No Jurisdiction	Claimant files an RFA-1, checking box “i”, first sub-box

3. MTG Special Services (C-4Auth)

Special Services include 11 treatments: lumbar fusion, artificial disc replacement, vertebroplasty, kyphoplasty, electrical bone growth stimulator, osteochondral graft, autologous chondrocyte implantation, meniscal allograft transplantation, total or partial knee replacement, spinal cord stimulators, and pain pumps.

Review is not required by a carrier’s physician, IME, or record review when:

Treatment was already rendered;
A substantially similar or duplicate request is pending and has not been denied;
A substantially similar or duplicate request was denied and there is not new information to help support the request; or
The case was controverted, disallowed, cancelled, or the medical was closed with a Section 32 agreement.

Decision	Reason	Action
Granted	N/A	None
Denied without carrier physician review, IME, or record review	N/A	Claimant files RFA-1, citing denial as “factually inaccurate”
Denied by Claims’ Administrator even though medically necessary	Medically Necessary but Not Causally Related	Must be reviewed by carrier’s physician, IME, or record review.
Denied by Claims’ Administrator	Medical Reason	Automatically escalated to the carrier’s physician.
Denied	Claimant fails to appear at IME.	Denial upheld.
Denied by carrier’s physician	Not specific.	Claimant’s physician requests review by MDO within 10 days of the denial.
IME denies	Based upon IME report	Claimant files RFA-1 or Claimant’s physician requests review by MDO
MDO denies	N/A	Claimant files RFA-1
Denied	Administrative or No Jurisdiction	Claimant files an RFA-1, checking box “i”, first sub-box

4. Non-MTG over $1,000 (C-4Auth)

This is consistent with a C-4Auth. These are requests costing over $1,000 without an applicable MTG category.

Review can be performed by a carrier’s physician, IME, or record review. Review is not required when:

Treatment was already rendered;
A substantially similar or duplicate request is pending and has not been denied;
A substantially similar or duplicate request was denied and there is not new information to help support the request; or
The case was controverted, disallowed, cancelled, or the medical was closed with a Section 32 agreement.

Decision	Reason	Action
Granted	N/A	None
Denied By Claims’ Administrator without review by Carrier Physician	N/A	Claimant files RFA-1, citing denial as “factually inaccurate”
Denied by Claims’ Administrator even though medically necessary	Medically necessary, but not casually related.	Must be reviewed by carrier’s physician, IME, or record review.
Denied by Claims’Administrator	Medical Reason.	Automatically escalated to the carrier’s physician.
Denied	Burden of Proof	Automatically escalated to the carrier’s physician as medical rationale is required.
Denied	Controverted Case	IME deemed waived if the case is later established unless the carrier presents a contrary medical opinion at the time of the denial.
IME denies	Not specific.	Claimant files RFA-1 or Claimant’s physician requests review by MDO
MDO denies	N/A	Claimant files RFA-1
Denied by carrier’s physician	Medical reasons	No request from a party is necessary. The Board will schedule an expedited hearing.
Denied	Administrative or No Jurisdiction	Claimant files an RFA-1, checking box “i”, first sub-box

5. Non-MTG under $1,000 (new)

This is a new category for which there was not a form before PAR. This PAR is submitted when a provider seeks treatment for a body part or condition not covered by the MTGs and the treatment costs less than $1,000.

If the case was controverted, disallowed, cancelled, or the medical was closed with a Section 32 agreement, then carrier physician review is not required. In all other cases, the carrier’s physician must partially grant treatment or deny.

The carrier has eight calendar days to respond.

Decision	Reason	Action
Granted	N/A	None
Denied without carrier physician review, IME, or record review	N/A	Claimant files RFA-1, citing denial as “factually inaccurate”
Denied without physician review, but concedes medically necessary	Medically necessary, but not causally related.	Denial invalid and must be approved
Denied	Claimant fails to appear at IME.	Denial upheld.
Denied by carrier’s physician	Not specific.	Treating provider requests review and Board issues Proposed Decision. Claimant or carrier may object to Proposed Decision within 30 days. Provider may not object to Proposed Decision.
Denied with carrier physician review	Does not confirm medical necessity	Physician requests review from MDO within 10 calendar days
Denied	Administrative or No Jurisdiction	Claimant files an RFA-1, checking box “i”, first sub-box

6. Medication (Drug Formulary)

The PAR process for medications is different than other PAR requests. Even if a claimant is already taking a medication, medical providers must request prior authorization for:

Phase A formulary drugs
Phase B formulary drugs
Perioperative formulary drugs
Brand name drugs that are available in generic form
Drugs not provided for in the formulary
Compound drugs
Formulary drugs being used in a manner inconsistent with the MTGs

There are three levels of review. The carrier has four calendar days to respond to Level 1 and Level 2 reviews.

Level 1: Provider requests prior authorization from carrier and pharmacy network (if applicable). Non-Formulary drugs must be specific with duration and quantity.

Denials must include:

Specific reason for the denial
Directions to request review from the carrier’s physician

The requesting provider must ask for Level 2 review within 10 days of a denial.

Level 2: Must be reviewed by the carrier’s physician. If the carrier fails to respond, the Board may issue an Order of the Chair.

The requesting provider must ask for Level 3 review within 10 days of the Level 2 denial with all supporting documentation from Levels 1 and 2.

Level 3: MDO review

If the MDO denies the request, the claimant may file an RFA-1, showing the drug is:

Medically necessary
Denial adversely effects the claimant’s interests

Durable Medical Equipment (new)

A PAR request must be placed for DME when the DME is not on the Official New York Workers' Compensation Durable Medical Equipment (DME) Fee Schedule or the item on the fee schedule requires prior authorization with the designation of "PAR."

The carrier has four calendar days to respond.

Decision	Reason	Action
Granted	N/A	None
Denied without review	N/A	Claimant files RFA-1, citing denial as “factually inaccurate”
Denied even though medically necessary	Medically necessary, but not causally related.	Must be reviewed by carrier’s physician, IME, or record review.
Denied by Claims’ Administrator	Medical Reason	Automatically escalated to the carrier’s physician.
Denied	Burden of Proof	Automatically escalated to the carrier’s physician as medical rationale is required.
Denied	Controverted Case	IME deemed waived if the case is later established unless the carrier presents a contrary medical opinion at the time of the denial.
IME denies	Based upon IME report.	Claimant files RFA-1 or Claimant’s physician requests review by MDO
MDO denies	N/A	Claimant files RFA-1
Denied	Administrative or No Jurisdiction	Claimant files an RFA-1, checking box “i”, first sub-box

Notes for eCase Users

When using eCase, the following can help identify the level and type of PAR request.

Confirmation PARs

Level 1

MG1-L1 - MTG Confirmation Level 1 Request
MG1-L1A - MTG Confirmation Level 1 Request Amended

Level 3

MG1-L3G - MTG Confirmation Level 3 Grant
MG1-L3GP - MTG Confirmation Level 3 Grant in Part
MG1-L3D - MTG Confirmation Level 3 Denial

Grant/Denial/Decision (no Level indicated)

MG1-CG - MTG Confirmation Insurer Grant
MG1-CGP - MTG Confirmation Insurer Grant in Part
MG1-CD - MTG Confirmation Insurer Denial
EC-325-MG1 - MTG Confirmation Order of the Chair
MG1-GAD - MTG Confirmation Insurer Grant After Denial

Variance PARs

Level 1

MG2-L1 - MTG Variance Level 1 Request
MG2-L1A- MTG Variance Level 1 Request Amended

Level 3

MG2-L3 - MTG Variance Level 3 Request
MG2-L3G - MTG Variance Level 3 Grant
MG2-L3GP - MTG Variance Level 3 Grant in Part
MG2-L3D - MTG Variance Level 3 Denial
MG2-L3NA - MTG Variance Level 3 No Action

Grant/Denial/Decision/Other (no Level indicated)

MG2-CP - MTG Variance Insurer IME Scheduled
MG2-CG - MTG Variance Insurer Grant
MG2-CGP - MTG Variance Insurer Grant in Part
MG2-CD - MTG Variance Insurer Denial
EC-325-MG2 - MTG Variance Order of the Chair
MG2-GAD - MTG Variance Insurer Grant After Denial

Special Services PARs

Level 1

SS-L1 - MTG Special Services Level 1 Request
SS-L1A - MTG Special Services Level 1 Request Amended

Level 3

SS-L3 - MTG Special Services Level 3 Request
SS-L3G - MTG Special Services Level 3 Grant
SS-L3GP - MTG Special Services Level 3 Grant in Part
SS-L3D - MTG Special Services Level 3 Denial
SS-L3NA - MTG Special Services Level 3 No Action

Grant/Denial/Decision/Other (no Level indicated)

SS-CP - MTG Special Services Insurer IME Scheduled
SS-CG - MTG Special Services Insurer Grant
SS-CGP - MTG Special Services Insurer Grant in Part
SS-CD - MTG Special Services Insurer Denial
SS-GAD - MTG Special Services Insurer Grant After Denial

Non-MTG PARs over $1,000

Level 1

O1K-L1 - Non-MTG Over $1000 Level 1 Request
O1K-L1A - Non-MTG Over $1000 Level 1 Request Amended

Grant/Denial/Decision/Other (no Level indicated)

O1K-CG - Non-MTG Over $1000 Insurer Grant
O1K-CGP - Non-MTG Over $1000 Insurer Grant in Part
O1K-CD - Non-MTG Over $1000 Insurer Denial
EC-325-O1K - Non-MTG Over $1000 Order of the Chair
O1K-GAD - Non-MTG Over $1000 Insurer Grant After Denial

Non-MTG PARs under $1,000

Level 1

U1K-L1 - Non-MTG Under Or = $1000 Level 1 Request
U1K-L1A - Non-MTG Under Or =$1000 Level 1 Request Amended

Level 3

U1K-L3 Non-MTG Under Or =$1000 Level 3 Request

Grant/Denial/Decision/Other (no Level indicated)

U1K-CG - Non-MTG Under Or =$1000 Insurer Grant
U1K-CGP - Non-MTG Under Or =$1000 Insurer Grant in Part
U1K-CD - Non-MTG Under Or =$1000 Insurer Denial
EC-325-U1K - Non-MTG Under Or =$1000 Order of the Chair
U1K-GAD - Non-MTG Under Or =$1000 Insurer Grant After Denial

Medication PARs

Level 1

RX-L1 - Medication Level 1 Request
RX-L1A - Medication Level 1 Request Amended
RX-L1G - Medication Level 1 Grant
RX-L1GP - Medication Level 1 Grant in Part
RX-L1D - Medication Level 1 Denial

Level 2

RX-L2 - Medication Level 2 Request
RX-L2G - Medication Level 2 Grant
RX-L2GP - Medication Level 2 Grant in Part
RX-L2D - Medication Level 2 Denial

Level 3

RX-L3 - Medication Level 3 Request
RX-L3G - Medication Level 3 Grant
RX-L3GP - Medication Level 3 Grant in Part
RX-L3D - Medication Level 3 Denial

Decision Issued

EC-325-RX - Medication Order of the Chair

DME PARs

Level 1

DME-L1 - Durable Medical Equipment Level 1 Request
DME-L1A - Durable Medical Equipment Level 1 Request Amended

Level 3

DME-L3 Durable Medical Equipment Level 3 Request
DME-L3G Durable Medical Equipment Level 3 Grant
DME-L3GP Durable Medical Equipment Level 3 Grant in Part
DME-L3D Durable Medical Equipment Level 3 Denial

Grant/Denial/Decision (no Level indicated)

DME-GAD Durable Medical Equipment Insurer Grant After Denial
DME-CD Durable Medical Equipment Insurer Denial
DME-CG - Durable Medical Equipment Insurer Grant
DME-CGP Durable Medical Equipment Insurer Grant in Part
EC-325-DME Durable Medical Equipment Order of the Chair

Whereas this is only an outline of the new PAR system we hope it is helpful for medical providers and claimant’s to be able to obtain work related medical treatment in a timely fashion.

The Latest New Laws In Workers Compensation