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New York State
Workers' Compensation Board
OFFICE OF THE CHAIR
20 Park Street   Albany, New York 12207
Governor David A. Paterson


Subject No. 046-255

Objections to Medical Treatment and Medical Bills:
Revised Form C-8.1 and New Form C-8.4

Date: October 3, 2008

The Reform Legislation of 2007 has served as the impetus for reengineering several of the Board's procedures relating to medical treatment. In an effort to make medical reports and authorization requests for special medical services more responsive to the needs of the claimant, employer, carrier, medical provider, and the Board, Form C-4 (Doctor's Initial Report) was modified and new Forms C-4.2 (Doctor's Progress Report) and C-4.3 (Doctor's Report of MMI/Permanent Impairment) were introduced on September 17, 2008. The redesign effort focused on more user-friendly forms while collecting information needed to more quickly process and resolve claims, thereby speeding medical treatment to deserving injured workers.

Along with the core C-4 forms, the new Form C-4AUTH (Attending Doctor's Request for Authorization and Carrier's Response) was introduced on September 17th as well. This new form will serve as the vehicle by which a doctor can request authorization for a special medical service and a carrier can respond to the request. Because time is of the essence when medical treatment is involved, the Board will track authorization requests made on Form C-4AUTH, ensuring that all statutory timeframes are met.

Workers' Compensation Law § 13(a) provides that medical care should be rendered "promptly," and § 13-a provides that authorization requests for special services should not be "unreasonably withheld." 12 NYCRR 325-1.4 allows the carrier 30 days (4 if the claimant is hospitalized) to respond to an authorization request. If a reponse is not forthcoming within those timeframes, the request is deemed authorized by operation of law and the Chair may issue "an order stating that such request is deemed authorized." If a denial of the authorization is made within those 30 days (4 days if a claimant is hospitalized), it must be accompanied by a conflicting second opinion rendered by a physician authorized to treat workers' compensation claimants. 12 NYCRR 300.23(d) further provides that if the carrier shall terminate medical care or refuse authorization for a special medical service, Form C-8.1 (Notice of Treatment Issue(s)/Disputed Bill Issue(s)) shall also be filed with the Board.

In an effort to coordinate its medical forms regarding treatment, authorization for special medical services, and objections to medical treatment and bills, the Board on September 17th also released a revised Form C-8.1 and new Form C-8.4.

Form C-8.1 in Part A requires the carrier (1) to clearly specify the legal reason for its objection to authorization of a special medical service or to further treatment and (2) to provide information on its conflicting second opinion when one is necesary. Clarifying the objection raised will provide the Board with the information it needs to expeditiously resolve the controversy over medical care. Resolution will be in the form of an Order of the Chair (Form EC-325) for objections that are untimely and/or deficient or in the form of an expedited hearing before an Administrative Law Judge for those objections which are both timely and accompanied by a conflicting medical opinion.

Likewise, Form C-8.1 in Part B requires the carrier to specify the legal reason for its objection to the payment of a bill. Clearly stated on both the front and the reverse side of Form C-8.1 are the time requirements for an objection to a bill: 45 days after the bill has been submitted by the provider. Legal objections to a bill will be resolved by a Conciliator or Administrative Law Judge, with examination focusing first on whether the legal objection to the bill was timely raised and whether the objection was a proper legal objection. The objection must be both timely and proper before the merits of the objection can be reached.

Because it is easy to confuse legal objections and "valuation" objections to a bill, the Board has created new Form C-8.4 (Notice to Health Care Providers and Injured Worker of a Carrier's Refusal to Pay all [or a portion of] a Medical Bill Due to Valuation Objection[s]). While the form is not presently mandatory, carriers are encouraged to utilize this form when raising "valuation" issues with a provider. The reverse side of Form C-8.1 and the new Form C-8.4 detail the objections which are considered "valuation" objections. Resolution of "valuation" issues relates to the Board's fee schedule for New York State WCB authorized providers and is confined by WCL §13-g and 12 NYCRR 325-1.24 to a process coordinated through the Board's Health Provider Administration (HPA). Legal objections, now clearly provided on Form C-8.1 Part B, are resolved through the Board's Adjudication Divison.

The Board encourages all participants in the workers' compensation system to become familiar with the modifications to Form C-8.1 and with new Form C-8.4, which are effective immediately, and to begin using the forms as soon as possible. Earlier versions of Form C-8.1 may not be submitted after December 31, 2008. The new and revised forms are now available on the Board's web site, www.wcb.ny.gov. Use of these new forms along with a renewal of the Board's commitment to insure timely resolution of medical issues will insure that injured workers are treated promptly and that legal and valuation objections, when made timely, are resolved promptly in the proper forum.

 

Zachary S. Weiss
Chair