In accordance with Subpart 325-8 of Title 12 NYCRR, all insurance carriers who have contracted with a preferred provider organization (PPO) for the treatment of workers' compensation injuries and illnesses shall report to the Chair pertinent information related to insured employers who have elected to utilize the preferred provider organization.
In order to fulfill the above reporting requirements, insurance carriers shall submit to the Workers' Compensation Board a copy of
- completed New York Compensation Insurance Rating Board's Preferred Provider Organization Endorsement (WC 31 06 16) or
- New York Preferred Provider Organization Premium Endorsement (WC 31 04 03)
for each individual employer electing to utilize a PPO certified by the New York Department of Health under Article 10-A of the Workers' Compensation Law.
The endorsement should identify the employer's full legal name as well as any other name under which business is conducted and a current address for work sites included in the program. If there is more than one insured employer on a single policy, each insured which will be utilizing the PPO and its respective address should be listed on the endorsement. If any insured employer which will be utilizing a PPO operates in a unionized setting, the inclusion or exclusion of unionized employees in the PPO arrangement shall be noted either on the endorsement or on an attachment.
Subpart 325-8 of Title 12 NYCRR also requires that, where there is a duty to collectively bargain, an employer must engage in such bargaining with respect to PPO participation and must file with the Board a notarized affirmation signed by the collective bargaining agent(s) confirming that the requisite negotiation of the selection of a PPO has taken place and that the particular union and individual agent(s) which have agreed to such PPO are the recognized or certified exclusive bargaining representatives of the covered employees.
All requested information and all notarized affirmations shall be filed with the Workers' Compensation Board within ten days of the effective date of PPO participation. Such endorsements may be delivered by mail, personal delivery or fax to:
Policy and Program Development
Workers' Compensation Board
328 State Street
Schenectady NY 12305
In order to verify endorsement information, the name and phone number of an insurance carrier contact person must also be provided.
Please note that PPO participation will be jeopardized by failure to file the requisite endorsements as well as the notarized affirmations.
Any questions or concerns related to this matter may be directed to (877) 632-4996.