Revised Procedures When Requesting Order of the Chair for Medical Authorization

Date:  November 24, 2003

The Workers' Compensation Board continues to strive for a prompt and fair resolution to all workers' compensation claims. As part of that effort, the Board continues to recognize the need for claimants to receive medical treatment as quickly as possible. Medical providers are required by law to seek prior approval for any procedure costing more than $500, but sometimes it is difficult to receive such approval in a timely fashion.

In 2002, the Workers' Compensation Board, recognizing this need, developed a procedure to enable medical providers to request Board intervention whenever providers receive no response to a request for prior approval from a carrier for a procedure costing more than $500. Upon the request of the health provider on Form MD-1, Attending Doctor's Request for Medical Authorization Determination, the Board may issue an Order of the Chair notifying the carrier or self-insured employer that the treatment requested is deemed authorized.

Effective December 1, 2003, the Board will amend the authorization process in order to provide a more prompt and certain resolution of authorization issues. The major changes are:

• Authorization requests in controverted cases will now be accepted and Orders of the Chair issued, if appropriate. However, the carrier or self-insured employer shall not be responsible for payment in these cases unless and until the question of compensability is resolved in favor of the claimant.
• Previously, the carrier or self-insured employer could file an objection to the Order of the Chair within ten days after the Order was filed, using Form MD-3. Such objections will no longer be allowed after an Order is issued. Instead, the carrier or self-insured employer must file an objection, using the revised MD-3 form, with the Board within 10 days of the health provider's MD-1 request. The objection will be reviewed, and if it has merit, the issue will be referred to the Board's expedited hearing process. If it is without merit, the Order of the Chair will be issued and is final. An example of an objection with merit is one in which the carrier issued a proper and timely denial to the request.
• On Form MD-1, the individual mailing the form must complete and sign a statement at the bottom of the form certifying that a copy was mailed to the carrier or self-insured employer.
• Carriers will no longer be directed to provide written authorization to the claimant and the medical provider within ten days of the issuance of the Order of the Chair. Such authorization is not required by law and is no longer necessary as the Order of the Chair is final.

All prior requirements for filing Form MD-1 remain the same. Prior to requesting Board intervention, the health provider must:

1. contact the carrier or self-insured employer by telephone to request authorization
2. complete Board form C-4 with item 4 checked "yes" requesting authorization
3. send the C-4 form to the carrier and the Board
4. wait 30 calendar days for either a written approval from the carrier or a denial based on a contrary medical report

If after 30 calendar days the carrier or self-insured employer has not responded to the authorization request by either approving or denying the request, the medical provider may submit the MD-1 form requesting Board intervention.

When the Board receives Form MD-1 it will verify that the medical provider has properly requested authorization and that the carrier has neither approved nor denied the request. If the request was proper and there is no evidence that the carrier has responded, and if a timely, meritorious objection has not been filed, the Board will then issue an Order of the Chair. If the case is not controverted, the order will direct the carrier or self-insured employer to pay for the medical services requested immediately. If compensability of the claim is controverted, the Order will direct that the carrier or self-insured employer is not responsible for paying for the medical treatment/services until the controversy has been resolved in the claimant's favor.

If the request for an Order of the Chair is not proper, i.e., the medical provider failed to perform one of the four steps listed above, then the Board will return form MD-1 with an explanation of why the request has been rejected. The medical provider may correct the oversight and resubmit the request, unless the carrier or self-insured employer filed an objection which had merit.

The new forms and procedures will be effective December 1, 2003. Revised Forms MD-1 (12-03) and MD-3 (12-03) are now available on the Board's web site (www.wcb.ny.gov) under the heading "Common Forms Online." Effective December 1, 2003, only the revised Form MD-1 will be accepted; prior versions will be returned to the medical provider. Superseded versions of Form MD-3 will only be accepted in cases where Form MD-1 was submitted before December 1, 2003. If a prior version of Form MD-3 is submitted in a case where Form MD-1 was submitted after December 1, 2003, it will be returned to the carrier/self-insured employer and the time in which to file an objection will not be extended. Form MD-4, Carrier/Self-Insured Employer's Objection to Board's Affirmance of Order of the Chair Authorizing Special Services, is eliminated under the revised procedure and must no longer be filed.

Thank you for your cooperation.

Jeffrey R. Sweet
Acting Chairman