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  1. So, only new medications being prescribed go through the Medical Portal? Continued medications go on Form MG-2?
    1. Effective December 5, 2019, all new prescriptions must comply with the New York Workers' Compensation Formulary (NY WC Formulary). A new prescription is for a medication the injured worker is not then currently taking or an increased strength of a medication they are taking. Requests for non-formulary medications will go through the Medical Portal process.

      Renew/refill prescriptions must comply by June 5, 2020. A renew/refill is a medication the patient has been then currently taking or the same medication in a lower strength. Requests for non-formulary medications will need to go through the Medical Portal process.

  2. If time elapses, does the Portal automatically update the decision status (i.e., four days elapsed, no response; status turns to approved)?
    1. Yes, and notifies the prescriber, the indicated Pharmacy Benefits Manager and the Carrier/Self-Insured.
  3. Is there an email push to notify the Level I reviewer that a new review is ready?
    1. When the prescriber submits the Level I or Level II review request, the Level I or Level II contact receives an email notification that a request has been submitted. The request is routed to a workload administrator's dashboard. When the workload administrator assigns the request to a reviewer, the request will appear on the reviewer's dashboard. To see and act on the request, the reviewer must access their dashboard.
  4. Are we able to obtain a medical decision like an Order of the Chair on the Portal?
    1. An issued Order of the Chair (OOC) will be emailed to the submitting prescriber and filed in the injured worker's eCase folder.
  5. Can you upload medical documents to the Portal?
    1. When submitting a Level I prior authorization request, or requesting next level review of a denied or partially approved Level I or Level II request, the prescriber must directly respond to the reviewer's rationale for the denial or partial approval. This can be done by either entering free text onto the prior authorization form and/or attaching supporting documentation.
  6. Can you see past decisions in the Portal?
    1. Currently, prior authorization requests will remain on the dashboard indefinitely. The Board is reviewing archival options to make the dashboard more streamlined while providing an option for reviewing pervious prior authorization requests.
  7. Right now, pharmacies alert the Pharmacy Benefits Manager/third party to any pending drug that requires prior authorization per the New York Workers' Compensation Medical Treatment Guidelines (NY WC MTG). Carriers can choose to approve as necessary right now. How will this work once the dashboard is live?
    1. All submitted prior authorization requests will be visible on the dashboards and should be reviewed and approved via the dashboard.
  8. Can midlevel providers submit prior authorization requests, etc. to the Portal?
    1. All providers submitting prior authorization requests will do so via the Medical Portal. This includes all current provider types authorized to treat workers' compensation patients and eligible to prescribe, as well as the new provider types that are eligible to prescribe.
  9. Can some insurance companies opt out of the Portal or are they required to use it?
    1. All carriers and self-insured employers are required to utilize the prior authorization process for non-formulary prescription requests as access through the Board's Medical Portal.
  10. So, how would we know in an authorization department when a prior authorization is needed? We depend on the pharmacy to inform us when prior authorization is needed.
    1. Prescribers are responsible for submitting prior authorization requests before the medication is prescribed.
  11. Can more than one medication be submitted for a patient on a single prior authorization request? The text box allows you to enter more than one medication.
    1. Although the text box does not limit the number of medications that can be entered, the Prior Authorization Request process is not designed to accept more than one medication on a single prior authorization request. If more than one medication is being requested for a patient, each medication must be submitted on a separate prior authorization request. Prior authorization requests that contain more than one medication will be denied.
  12. What if the patient takes a prescription to the pharmacy prior to the prior authorization being received?
    1. If the patient presents at the pharmacy with a prescription for a non-formulary medication the pharmacy may either (a) refer the patient back to the prescriber or (b) reach out to the prescriber directly informing them that an approved non-formulary prior authorization is required before the prescription can be filled.
  13. When do you use Form MG-2 vs a prior authorization form?
    1. The MG-2 will only be used for medical marijuana, all requests for prior authorization of non-formulary medications should be submitted via the new electronic process.
  14. Will the pharmacies be submitting these new prior authorization requests? Currently, at the MD's office we only submit authorization requests on Form MG-2 or Form C-4 AUTH. The pharmacies handle all drug requests.
    1. Requests for non-formulary medications should be submitted by the prescriber before the prescription is written.
  15. On Level II reviews - can a DRN transcribe the Medical Director's opinion in the Portal? Or must we have a physician do this clerical function?
    1. Prescribers will need to use their NY.Gov credentials to log into the Medical Portal and submit prior authorization requests.
  16. Does the Level II reviewer need to be a certified NYS Workers' Compensation provider?
    1. The Level II reviewer must be the "Carrier's Physician" as defined in Subchapter M of Chapter V of Title 12 of NYCCR Part 441.1(g)
  17. The Hartford has a URAC approved Utilization Review program and utilizes Peer Reviews. Is this acceptable to the Board for Level II reviews?
    1. If the carrier wishes to use a URAC accredited company to perform Level II reviews, they should seek, in writing, approval from the Chair of the Workers' Compensation Board.
  18. Does a URAC Independent Review Organization who has Level II reviewers, need to be approved by the NY Board?
    1. Yes, via a request to the Chair of the Workers' Compensation Board, 328 State Street, Schenectady, NY 1235
  19. When we request the variance after a Level I denial, what criteria will the reviewing physician be utilizing to render a decision? Is it simply based on the submitted rationale or are there specific guidelines which they are expected to follow?
    1. There are no specific guidelines required for the review. However, the reviewer (both Level I and Level II) is expected to explicitly respond to the prescriber's request for the non-formulary medication. NOTE: Upon implementation of the prior authorization system, variance for non-formulary medications will no longer be utilized. All requests will go through the prior authorization system.
  20. Where are the prior authorizations routed to? The Level I reviewer? If the Level I reviewer, how does the Level I reviewer get alerted that a prior authorization is pending?
    1. The Level I or Level II contact will receive an email notification that a new item has appeared on the dashboard and needs to be assigned to a reviewer. The reviewer will not receive an email notification but will see all assigned requests on his/her dashboard.
  21. How long does the Medical Director's office have to respond to a Level III request?
    1. The regulation does not specify a specific time frame. However, it is expected that Level III review will be completed in seven to ten days.
  22. If providers do not enter information for prior authorization, will the Pharmacy Benefits Manager or adjuster be able to input to begin the process?
    1. All prior authorization requests should be submitted by the prescriber by accessing the Medical Portal. This should be done before the non-formulary medication is prescribed or dispensed.
  23. Can a medication which varies from the NY WC Formulary or Medical Treatment Guidelines (NY WC MTG) still be requested using Form MG-2 or C-4 AUTH?
    1. No. Effective December 5, 2019, Form MG-2.0 and/or Form C-4 AUTH are no longer the appropriate forms for medication requests, with the exception of medical marijuana, which still requires the use of Form MG-2.0. The Board will take no action on a submitted MG-2 or C-4 AUTH request for medication. Providers who want to request a non-formulary medication or a medication not meeting NY WC MTG criteria must submit a Prior Authorization request through the Medical Portal process. NY WC Formulary drugs do not require prior authorization. For more information, please visit the Board's New York Workers' Compensation Formulary Overview webpage.
  24. Will MG-2 forms still be accepted for continued medications after December 5, 2019?
    1. No, all requests for non-formulary medications will need to go through the Medical Portal process effective December 5, 2019. This includes both requests for new medications as well as requests for non-formulary renewal/refills.

Formulary

  1. Where is the perioperative drug list found?
    1. The New York Workers' Compensation Formulary (NY WC Formulary) is arranged by therapeutic category and then by the generic name of the medication. The applicable phase for which each medication is included is then indicated by an "x" under the respective phase(s) of the NY WC Formulary; Phase A, Phase B or Perioperative Phase.
  2. Will the NY WC Formulary be updated with the NY WC MTG and Special Consideration 4 prior to Dec 5?
    1. A revised version of the NY WC Formulary, which included Special Consideration 4, was released as an emergency regulation and opened for public comments on November 5, 2019.
  3. How is the conflict between the Non-Acute Pain NY WC MTG and Formulary handled with respect to opiates?
    1. All request for opioids, other than the single dispensing of a seven-day supply within Phase A of the NY WC Formulary would necessitate prior authorization. By December 5, 2019, providers will be receiving from the insurance carriers a list of their patient who are currently taking non-formulary medications (which would include chronic opioids). Refills of current prescriptions must comply with the formulary by June 5, 2020. Prescribers have six months to either change the injured worker to a formulary agent, or to request a prior authorization for a non-formulary agent.
  4. For a drug that is not associated with any NY WC MTG (such as antihistamine), is prior authorization required for Phase B drugs? Based upon what was stated earlier, it seems like it does, but that is not indicated in the Prior Authorization required guidelines.
    1. To address this issue, Special Consideration 4 was recently added - As clinically indicated for causally related injuries or conditions utilizing accepted standards of medical care. This means that the medication can be prescribed and dispensed:

      • When there is no adopted NY WC MTG for the established / accepted body part of condition, and/or
      • For a condition directly associated with an established / accepted body part, but not specifically addressed in the NY WC MTG.

      Example: treatment of a post-operative infection following a knee replacement.

  5. Is there a protocol for patients who are long-time opioid users? Is there a process that they fit into beyond phase B?
    1. Long-term opioid prescriptions would need prior authorization, which can be for up to a 365-day supply.
  6. Is Step Therapy a requirement? And if so, does it only pertain to Phase B drugs designated as "2nd"?
    1. The NY WC Formulary does not formally incorporate "Step Therapy". Although there is no required duration of use for a "yes" drug, a "2nd" drug would be deemed appropriate if the "yes" drug has been tried by the injured worker and discontinued due to a provider documented:
      • lack of efficacy or effectiveness, or
      • diminished effectiveness, and/or
      • an adverse event
        or
      • Would be considered contraindicated because of the injured worker's comorbid condition(s).
  7. After the 90-day supply of a Phase B drug, does a request for prior authorization need to be filed for each refill?
    1. After a 90-day supply of a Phase B drug has been exhausted, a new prescription, for up to a 90-day supply, would need to be written.
  8. Are any long-acting opiates allowed? I don't see any on the NY WC Formulary.
    1. There are no long-acting opioids on the NY WC Formulary. Therefore, they would require prior authorization before they can be prescribed and dispensed.
  9. Will there be a column on the NY WC Formulary for Occupational Interstitial Lung Disease?
    1. As new NY WC MTG are adopted, the NY WC Formulary will be updated to include the corresponding medications. New NY WC MTG will have their own column on the NY WC Formulary, consistent with the current format.
  10. How often are NY WC Formulary changes expected?
    1. The NY WC Formulary will be updated as new NY WC MTG are adopted and as submitted requests for new medications are received and approved by the Board.
  11. If the patient is currently prescribed a drug not on the NY WC Formulary, is the deadline for prior authorization June 5, 2020?
    1. All refills/renewals of current medications must comply with the NY WC Formulary by June 5, 2020. Requests for prior authorization of these medications can be submitted any time after the prior authorization process goes live. NOTE: A request for a non-formulary medication can be made for up to a 365-day supply. If such a request is granted, the prescriber should write the prescription(s) consistent with applicable state laws.
  12. If a patient develops a reaction to an authorized medication, can another type of medication be requested?
    1. The prescriber can submit a request for a prior authorization at any point he/she feels it appropriate.
  13. Psychiatric conditions are not listed as an injury site. What will this mean regarding NY WC Formulary approvals?
    1. There are items on the NY WC Formulary for the treatment of psychiatric conditions. In that psychiatry related NY WC MTG have not yet been adopted, these medications are labelled with Special Consideration #4 and may be utilized accordingly.
  14. What about pain patches-for example, Lidoderm patch (dispensed by the pharmacy)?
    1. The NY WC Formulary contains both prescription and non-prescription items (e.g., lidocaine 4% patches). If a formulary OTC is written on a prescription, the pharmacy should fill and process the prescription for the OTC item. Pain patches not specifically listed on the NY WC Formulary would require prior authorization before they could be dispensed.
  15. Anticonvulsants are all listed as "2nd" in the NY WC Formulary. If any medication listed as "Yes" is trialed and failed, can an anticonvulsant then be prescribed, or is there a specific medication or class of medication that needs to be trialed and failed first?
    1. Medications designated as "2nd" may be utilized after a "yes" for the associated NY WC MTG has been utilized.

      Although there is no required duration of use for a "yes" drug, a "2nd" drug would be deemed appropriate if the "yes" drug has been tried by the injured worker and discontinued due to a provider documented:

      • lack of efficacy or effectiveness, or
      • diminished effectiveness, and/or
      • an adverse event
        or
      • Would be considered contraindicated because of the injured worker's comorbid condition(s).

Medical Portal

  1. When will the providers be able to access the Portal?
    1. Providers will be granted access to the Portal on a rolling basis over the next month, based on provider type. Notifications will be sent using the email address submitted by the provider during their registration. To prepare to access the Portal, providers should be sure they're registered to access the Portal now. A video on how to register for the Portal is available on the Medical Portal Overview page.
  2. I have over two hundred providers and extenders. Will each provider need to have their own login to submit? Will we have our own login to access their accounts? Providers do not regularly do authorizations themselves. Please advise.
    1. Individual prescriber credentials are required to access the Medical Portal, submit prior authorization requests and to access the provider-specific dashboard.
  3. What is the specific website for the Medical Portal?
    1. The Medical Portal can be access from the Board's home page using the "Log in to Access" drop down in the upper right corner which will take the user to the NY.Gov log in screen.
  4. How do they get an NY.Gov ID?
    1. An overview of the Medical Portal, and specific information on getting an NY.Gov ID and accessing the Portal can be found on the Medical Portal Overview page.
  5. Will the Dashboard list requests that have not yet been addressed in bold, or is there any distinction to the newest vs oldest and those that have not yet been responded to?
    1. Newest cases will default to the top of the dashboard. The dashboard can be sorted and filtered based on any of the data elements that appear.

Timing

  1. Are the four-day or ten-day time frames business or calendar days?
    1. All time frames are calendar days, which include weekends and holidays.
  2. If the carrier fails to timely respond to the prior authorization request, how long would it take for the Board to act on an Order of the Chair?
    1. If the Level I or Level II review does not occur in the designated time frame, an issued Order of the Chair would be immediate.
  3. Is there an expiration to the authorization?
    1. A prior authorization request may be submitted by the prescriber, for up to a one-year supply of the non-formulary medication.
  4. How many days can the provider submit the authorization before the refill date?
    1. A prior authorization request may be submitted at any time. New prescriptions must comply with the NY WC Formulary by December 5, 2019; refill prescriptions must comply by June 5, 2020. Providers will be receiving a list of their workers' compensation patients currently taking non-formulary medications on or about December 5, 2019, so they can either switch to a Formulary medication or request a prior authorization request well in advance of the June 5, 2020 deadline.

Expanded Provider

  1. Can a physician assistant get access to the Medical Portal as well?
    1. All Board authorized providers will be able to access the Medical Portal. The New Provider Legislation, which is effective January 1, 2020, expands the medical providers that can be authorized to treat injured workers to include licensed clinical social workers, nurse practitioners, acupuncturists, physician assistants, occupational therapists and physical therapists. If a provider is eligible to treat injured workers under the new legislation, as of January 1, 2020, they must be authorized by the Board. Information about the new provider legislation can be found on the New Provider Legislation page.
  2. There is no application for physician assistants to become a Board-authorized provider. When will that be available?
    1. Providers covered by the new provider legislation will be notified, via their email address on file with the New York State Department of Education, of their ability to request Board-authorization later this month.

Miscellaneous

  1. Will the Portal eventually be used for all treatment requests?
    1. The Board is currently reviewing the use of similar technology and processes for additional types of prior authorization requests (i.e., C-4 AUTH and MG-2).
  2. If the insurer/carrier approves the non-formulary drug for an out-of-state patient, would they be penalized if the provider did not go through the electronic prior authorization process? Are providers penalized/fined if they do not go through the dashboard?
    1. All prescribers treating NYS workers' compensation patients are required to comply with the NY WC Formulary and established prior authorization process. If an injured worker presents at the pharmacy with a prescription for a non-formulary medication for which a prior authorization request has not been submitted and approved, the injured worker should be referred to their provider.
  3. If a patient lives out of state, how does the patient get his/her prescriptions?
    1. Out of state patients will continue to get their prescriptions as they currently are. These prescriptions will need to comply with the NY WC Formulary and utilize the prior authorization process for non-formulary medications.
  4. Will out-of-state providers have to create a login to process a prior authorization request?
    1. All requests for prior authorization must go through the Medical Portal and established process.
  5. Did you say the prior authorization decisions are sent to the case folder? Who has access to that?
    1. Upon completion of each step in the process (e.g., submission of the request, decision of the Level I reviewer, prescriber's request for review of Level I denial, etc.), the prior authorization request is filed in the injured worker's eCase folder. The injured worker's eCase folder is available to all parties of interest in the case.
  6. Will the claimant's attorneys have access to the request process information as well?
    1. While attorneys will not have access to request prior authorization of medications, or a dashboard, all transactions associated with the prior authorization process will be filed in the injured worker's eCase folder. This is currently, and will continue to be, available to all parties of interest in the case.
  7. How will apportioned cases be handled in the dashboard?
    1. The primary carrier will be responsible for responding and for obtaining reimbursement from the secondary carrier.
  8. Is there is a way to try the Portal in a practice environment before it is active?
    1. At this point the Board is not able to provide the Portal to external stakeholders in a test environment.
  9. What if a body part is added later in the claim?
    1. Each medication considered formulary for the medical treatment body part is indicated with a "yes" on the NY WC Formulary.
  10. How often is the accepted body part updated on the dashboard? Who is updating it?
    1. Accepted body parts are not listed on the dashboard. Users can do a case search within the Portal at any time to see currently established body parts.
  11. What body part will be applicable if there are multiple body parts associated with the injury?
    1. All body parts that have been established in the case will be viewable.
  12. Have prescribers been notified not to write the script prior to approval? We are concerned that the prescriber will write the prescription preemptively, and the patient will submit it to the pharmacy before Level I review is completed.
    1. All WCB authorized providers have been notified of the training webinars that describe the new processes and requirements.
  13. Regarding medication, how are patients with multiples cases treated?
    1. The prescriber will do a case search and associate the request for the non-formulary medication with the selected case.
  14. Are the four new, yet to be released NY WC MTG (ankle/foot, hip/groin, elbow, occupational interstitial lung disease) still intended to be released by the end of 2019?
    1. The Board is currently reviewing the comments received from the public comment period.
  15. When will the Portal requests be rolled out for general NY WC MTG treatment besides drug formulary?
    1. The Board is currently reviewing options for using technology similar to that of the NY WC Formulary Prior Authorization process for other types of prior authorization requests.
  16. Then is the Health Commerce System account ID the same ID as well?
    1. Yes. Please review the "Signing up to Access the Medical Portal" video on the Medical Portal Overview page.
  17. Does the Level I reviewer complete the prior authorization request through the Portal?
    1. All transactions associated with a prior authorization request (i.e., submission and review) are done on the user's dashboard that is accessed via the Medical Portal.