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New York State
Workers' Compensation Board
OFFICE OF THE CHAIR
20 Park Street   Albany, New York 12207
Governor Eliot Spitzer


Subject No. 046-189

Use of Diagnostic Test Networks

To:State Insurance Fund, insurance carriers, self-insured employers, third party administrators, scheduling services and health care providers

Subject:Insurance carriers, self-insured employers and the state insurance fund may contract with a network to perform diagnostic testing, x-ray examinations, magnetic resonance imaging, or other radiological examinations or tests of claimants and may require claimants to undergo such special services with a provider that is affiliated with the network with which the carrier, self-insured employer or State Insurance Fund has a contract.

Date: May 10, 2007

The comprehensive workers' compensation reform bill signed into law by Governor Eliot Spitzer on March 13, 2007 now permits insurance carriers, self-insured employers and the state insurance fund to enter into contracts with networks to perform diagnostic testing, x-ray examinations, magnetic resonance imaging, or other radiological examinations or tests of claimants (hereinafter referred to as "diagnostic tests") and require claimants to obtain same from within such networks.

Specifically, section 13-a of the Workers' Compensation Law has been amended by adding a new subdivision 7, effective immediately on March 13, 2007, which provides the following:

  1. Notwithstanding any other provision of this chapter to the contrary, any insurance carrier authorized to transact the business of workers' compensation insurance in this state, self-insurer or the state insurance fund may contract with a network or networks, legally and properly organized, to perform diagnostic tests, x-ray examinations, magnetic resonance imaging, or other radiological examinations or tests of claimants and may require claimant to obtain or undergo such diagnostic test, x-ray examinations, magnetic resonance imaging or other radiological examinations or tests with a provider or at a facility that is affiliated with the network or networks with which the carrier contracts, except if a medical emergency occurs requiring an immediate diagnostic test, x-ray examination, magnetic resonance imaging or other radiological examination or test or if the network with which the insurance carrier, self-insurer or the state insurance fund contracts does not have a provider or facility able to perform the examination or test within a reasonable distance from the claimant's residence or place of employment, as defined by regulation of the board.
  2. Any insurance carrier, self-insurer or the state insurance fund which requires claimants to obtain or undergo diagnostic tests, x-ray examinations, magnetic resonance imaging or other radiological examinations or tests with a provider or at a facility affiliated with a network or networks with which it contracts, must notify the claimant of the name and contact information for the network or networks at the same time the written statement of the claimant's rights as required by subdivision two of section one hundred ten of this chapter or immediately after imposing such requirement if the time period within which the written statement of the claimant's rights as required by subdivision two of section one hundred ten of this chapter has expired.
  3. At the time a request for authorization for special diagnostic tests, x-ray examinations, magnetic resonance imaging or other radiological examinations or tests costing more than one thousand dollars as required by subdivision five of this section is approved, the insurance carrier, self-insurer or state insurance fund, or if so delegated the network with which the insurance carrier, self-insurer or state insurance fund has contracted, shall notify the physician requesting authorization of the requirement that the claimant obtain or undergo the special diagnostic test, x-ray examination, magnetic resonance imaging or other radiological examination or test with a provider or at a facility affiliated with the network or networks with which it has contracted, the contact information for the network and a list of the providers and facilities within the claimant's geographic location, as defined by regulation of the board. The claimant, in consultation with the provider who requested the special diagnostic test, x-ray examination, magnetic resonance imaging or other radiological test or exam, will determine the provider or facility from within the network which will perform such diagnostic test, x-ray examination, magnetic resonance imaging or other radiological examination or test.
  4. The results of the special diagnostic test, x-ray examination, magnetic resonance imaging or other radiological test or exam must be sent to the physician who requested the test or exam immediately upon completion of the report detailing the results.

(Emphasis added.)

Until the Board promulgates regulations addressing the specifics of the new law, this Subject Number is intended to provide highlights of the reform bill in order to assist employers, insurance carriers and the State Insurance Fund when requiring a claimant to utilize a designated network or provider for the purpose of scheduling diagnostic tests.

  • First: There are two exceptions to when an insurance carrier, a self-insured employer or the State Insurance Fund may require an injured worker to utilize a network provider or facility. First, in cases where a medical emergency occurs which requires the necessity of an immediate diagnostic test. Second, if the network does not have a provider available to perform the examination or test within a reasonable distance from the claimant's residence or place of employment.
  • Second: The claimant must be notified of the name and contact information for the network either at the time the written statement of the claimant's rights is provided in accordance with WCL §110(2), or immediately after imposing such requirement, if the time period within which the written statement of the claimant's rights as required by WCL §110(2) has expired.
  • Third: If the diagnostic test costs less than the threshold amount as set forth in WCL §13-a(5), no prior authorization is required.*
  • Fourth: At the time the request for authorization is made, the physician requesting the authorization shall be notified of the requirement that the claimant undergo the diagnostic test with a provider affiliated with the network.
  • Fifth: At the time the claimant receives his or her statement of rights as provided for in WCL §110, the claimant also must be furnished with the name and contact information for the network or networks. This includes a list of the network providers and facilities within the claimant's geographic location.
  • Sixth: The claimant has the right to choose the provider or facility from within the network who will perform the diagnostic test. The claimant may consult with the physician who requested that the diagnostic test be performed.
  • Seventh: The results of the diagnostic test must be sent to the physician who requested the test or exam immediately upon completion of the report detailing the results.

The Board is in the process of gathering information in order to promulgate regulations relating to insurance carriers, self-insured employers and the state insurance fund contracting with a network to perform diagnostic tests. Specifically, the Board is seeking input and comments on 1) what is a reasonable distance from the claimant's residence or place of employment to where the network providers are located; 2) what is a reasonable number of providers and facilities which the network must furnish to the claimant; and 3) how to define the claimant's geographic location. If you wish to provide written comments, please send them as soon as possible to:

Cheryl M. Wood, General Counsel
Office of General Counsel
New York State Workers' Compensation Board
20 Park Street, Room 401
Albany, New York 12207
or
OfficeofGeneralCounsel@wcb.ny.gov

*Please note that on and after July 11, 2007, the threshold amount above which prior authorization must be requested will increase to $1,000, pursuant to §28 of Chapter 6 of the Laws of 2007