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Glossary of WCB Terms

Workers' Compensation
(On-the-Job Injury or Illness)

Medical Benefits

The injured or ill worker who is eligible for workers' compensation will receive necessary medical care directly related to the original injury or illness and the recovery from his/her disability. The treating health care provider must be authorized by the Workers' Compensation Board, except in an emergency situation. You can find out more information about authorized providers and locate authorized providers in the Injured Workers or Health Care Providers sections of this website or by calling 1-800-781-2362. There are certain exceptions where insurance carriers or self-insured employers can direct medical treatment for the injured worker as described below:

Some injured or ill workers may require diagnostic tests, x-ray examinations, magnetic resonance imaging (MRI) or other radiological examinations or tests. As of March 13, 2007, insurance carriers, which includes self-insured employers and the State Insurance Fund, are authorized to contract with a legally and properly organized diagnostic networks to perform diagnostic tests, x-ray examinations, magnetic resonance imaging or other radiological tests or examinations or tests. In addition, insurance carriers may require claimants to obtain or undergo such diagnostic tests with a provider or at a facility that is affiliated with the network the carrier has contracted with, except when a medical emergency exists requiring an immediate diagnostic test or if the network does not have a provider or facility able to perform the diagnostic test within a reasonable distance from the claimant's residence or place of employment. The insurance carrier must notify claimants of the name and contact information for the network it has contracted with and is requiring claimants to use at the same time the written Statement of Claimant's Rights is sent or immediately after imposing the requirement if the time to send the Statement of Claimant's Rights has passed. Injured or ill workers should notify their medical providers if they receive notice that the insurance carrier requires the use of a network provider or facility for diagnostic tests.

The Workers' Compensation Law allows insurance carriers and self-insured employers to contract with New York State Health Department certified Preferred Provider Organizations (PPOs) to provide services, to diagnose, treat and rehabilitate an injured or ill worker requiring medical treatment. PPOs are required to make available at least two providers in every medical specialty and two hospitals. An injured worker is required to seek initial treatment with a provider affiliated with the PPO however, after initial treatment, he/she may select any authorized provider outside the PPO 30 days after the initial treatment.

The Workers' Compensation Law also allows, by negotiated labor agreement, a non-Workers' Compensation Board adjudication claim process called the Alternate Dispute Resolution(ADR) system for employers and employees in the unionized construction industry. Injured workers covered by the ADR program are required to obtain medical treatment from medical providers participating in the ADR program.

Beginning July 11, 2007, when a claimant or pharmacy submits a claim to an insurance carrier for payment or reimbursement of the cost of prescribed medicine for the work related injury or illness, the insurance carrier must pay the amount set forth in the Pharmacy Fee Schedule within 45 days of receipt of the claim, unless the claim has not been established or the prescribed medicine is not for a casually related condition. If the claim is not established or the prescribed medicine is not for an injury or illness related to the work accident or disease, the insurance carrier must pay any undisputed portion and notify the injured or ill worker or the pharmacy in writing within 45 days of receipt of the claim that the claim is not being paid, why it is not being paid and requesting any additional information needed to establish the claim.

Also, beginning July 11, 2007, insurance carrier may contract with a pharmacy or pharmacy network to provide prescribed medicines to injured or ill workers and may require injured or ill workers to obtain their prescribed medicines from such pharmacy or pharmacy network. The only exceptions are when a medical emergency occurs and it is not reasonably possible to obtain immediately required prescribed medicines from such pharmacy or pharmacy network or the pharmacy or pharmacy network does not offer mail order service and do not have a physical location within a reasonable distance from the claimant. If an insurance carrier requires injured or ill workers to use the pharmacy or pharmacy network it has a contract with, it must provide the injured or ill workers with notice which includes the contact information for the pharmacy or pharmacy network and instructions on how to obtain prescribed medicines.

The cost of necessary medical services is paid by the employer or the employer's insurance carrier, if the case is not disputed. The health care provider may not collect a fee from the patient. When appropriate, claimants will be awarded reimbursement for automobile mileage to and from a health care provider's office.

Health care providers may request that injured workers sign form A-9. This form is meant to provide notice to the injured worker that he or she may be responsible to pay the medical bills if the Workers' Compensation Board disallows the claim or the injured worker does not pursue the claim.