Skip to main content

Governor Hochul's legislation to increase injured workers' access to medical care has been enacted in the NYS Budget. Learn more!

Reminder: CMS-1500 electronic submission is mandatory

Back to menu

Preferred Provider Organizations Overview

Sections

Overview

The following highlights the statutory and regulatory provisions relative to Article 10-A of the Workers' Compensation Law. More information can be found in Subpart 325-8 of Title 12 NYCRR and the Department of Health (732-1 and 732-2, of Article 4 of Subchapter C of Chapter V of Title 10 of the Official Compilation of Codes, Rules and Regulations of the State of New York).

History

Chapter 635 of the Laws of 1996 authorized a number of initiatives intended to reform the current New York State Workers' Compensation System. This reform legislation modifies the New York State Workers' Compensation Law to authorize the insurance carriers and self-insured employers to contract with NYS Department of Health certified preferred provider organizations (PPOs) to provide services to diagnose, treat and rehabilitate a claimant requiring medical treatment of an occupational disease or injury.

Apply to become a PPO

Who may apply to become a PPO

Any plan or entity with the ability to establish a network of medical providers to treat all services covered under the WCL may apply for preferred provider organization (PPO) certification. No insurer or employer shall have any financial interest in the PPO.

How to apply

  • The Department of Health is responsible for the development, implementation and administration of a process for the certification and monitoring of participating PPOs.
  • To apply for certification, contact:
    Guy Boretti, Program Manager
    NYS Department of Health
    Corning Tower, Empire State Plaza
    Albany, N. Y. 12237
    (518) 474-5515
  • The application for PPO certification, shall be accompanied by a $500 application fee.

Requirements

Documentation required for certification

  • List and addresses of members of the governing body of the PPO which will be responsible for establishment of the PPOs policies, management and overall operation, including responsibility for adoption and enforcement of all policies governing health care services delivery, quality assurance and improvement, utilization review and all other PPO operations.
  • Certificate of Incorporation or proposed Certificate of Incorporation, bylaws, partnership agreement, and application for authority to do business in New York.
  • Independently audited financial statement of applicant.
  • Demonstration of character, competence, experience, and community standing of the medical director, members of the board, officers, owners, shareholders, and partners of the PPO.
  • Selection standards for participating providers.
  • Names and credentials, authorization to treat workers' compensation, licensing and certification requirements, and description of any final dispositions of professional misconduct for each provider/facility.
  • A description of times, places and manner of providing services under the PPO.
  • Procedures for ongoing Quality Assurance.
  • Procedures for Utilization Review consistent with Article 49 or a nationally recognized accrediting entity.
  • Procedures for Dispute Resolution consistent with Section 4408-A and Article 49 of the Public Health Law.
  • A description of how the PPO will meet the provider network criteria requirements.

Network criteria

  • Urban counties are required to have at least 1 Acute Care Hospital within the county and at least 1 other Acute Care Hospital available in contiguous counties. Rural counties should contain an Acute Care Hospital for claimant 40 miles or less within access of claimant's worksite or home. If not available in PPO, claimant has right to treat at nearest Acute Care Hospital.
  • PPO must ensure that at least two medical or health care providers will be made available in each county to claimants in each area of specialization required or offered, or:
    • document that there are not at least two physicians in a particular specialty in each country within the service area; and
    • document that there are at least two of the following specialty physicians under contract within each country within the proposed service area: family practice (board certified GP); orthopedic surgery, neurology, internal medicine; physical therapist; chiropractor and surgeon, and
    • document that there are at least two of the following specialty physicians under contract within a county or counties contiguous to one or more of the other counties which comprise the service area: anesthesiology, physical medicine and rehabilitation; psychiatry; psychology; radiology and dermatology; and
    • document that there are at least two of the following specialty physicians under contract within the Workers' Compensation Board district office service area: cardiology; pulmonary disease; ophthalmology; hand surgery; pathology; plastic surgery; urology; podiatrist; occupational therapist; neurological surgery; otolaryngology; thoracic surgeon; allergy and immunology; or
    • documentation indicating that the standards contained in subparagraphs listed above, cannot be met along with documentation, acceptable to the Commissioner, in consultation with the Chair, indicating how the PPO will provide claimants with an equivalent and accessible choice of practitioners.

General organizational and operating requirements

  • PPO shall have a governing body which will be responsible for establishment and oversight of the PPOs policies, management and overall operation.
  • PPO shall employ an administrator who shall be responsible for overseeing all facets of the operation.
  • PPO shall employ a medical director responsible for oversight of all aspects of medical care including the quality and appropriate utilization of services and development, updating and assurance of compliance with medical standards.
  • A PPO may enter into a management contract with an entity to oversee the management of the day to day activities of the PPO with respect to the performance of various services including: management information systems, utilization review, payment and medical dispute resolution and quality assurance. However, any such contract shall be effective only with the prior written consent to the Commissioner. A PPO may not enter into a management contract with a self-insured employer, an insurance carrier or with any entity owned or controlled by, or affiliated with such insurer to oversee the management of the day to day activities of the PPO with respect to the performance of quality assurance and medical dispute resolution.
  • PPO shall ensure access and availability to emergency care 24 hours a day.
  • PPO shall ensure access to initial treatment for all non-emergency care within 48 hours.
  • PPO shall develop and ensure a system which employees may obtain information on a 24 hours a day basis regarding the availability of medical services and emergency services.
  • PPO shall develop and require provider adherence to treatment standards and protocols.
  • The PPO shall maintain a return to work program in conjunction with the employer, treating physician and insurer to facilitate the return of injured workers to the workplace.

Reimbursement

A PPO shall not be required to reimburse for provider services in accordance with the provider fee schedules authorized pursuant to the Workers' Compensation Law. (Inpatient hospital fees are not negotiable, but tied to the Medicaid rate).

Decertification of a PPO

  • If the PPO does not meet compliance with the regulations, the Commissioner may revoke or suspend certification.
  • If the Commissioner deems that the PPO noncompliance was unintentional, a plan of correction may be requested. If plan of correction is carried out to the Commissioner's satisfaction, decertification will not occur.
  • If the PPO supplies false information in its application, the Commissioner may revoke or suspend certification.
  • Decertification of a PPO will be effective for three years and preclude the organization from operating or being affiliated in any manner with a certified PPO.

Records, reports and information requirements of the PPO

  • Clinical record shall be made available to the Commissioner by the PPO.
  • The PPO shall report to the Commissioner information regarding disciplinary action against any provider or information regarding professional misconduct.
  • All other business records and data management by the PPO, and relevant to the Commissioner's authority to oversee the activities of the PPO and to determine the appropriateness of the continued certification, shall be made available upon request.
  • PPO shall develop a detailed plan for providing affected employees with written notice of the PPO arrangement for the treatment of all workers' compensation injuries and illness.
  • The PPO shall develop a handbook to distribute to employers who will in turn distribute to employees on an as needed basis. The handbook shall contain all information needed by an employee to access services, the procedures for selecting and changing providers within the PPO network, a full explanation of all rights and responsibilities of the PPO, employer and employee when services are required, a detailed description of the policies and procedures of the PPO including utilization review, a description of the opt-out procedures for the employee, a description of the process for obtaining a second opinion, and a listing of all participating providers, including address, telephone number and their specialties.
  • If a provider ceases participation in the PPO, or if any provider becomes unavailable to provide services to any claimant, the PPO shall provide written notice to affected claimants within fifteen (15) days from the date that the organization becomes aware of such change in status. Such notice shall also include the procedures for choosing an alternate provider within the PPO and steps to be taken to ensure continuity of care.
  • PPOs must submit full and truthful reports of their findings to the employer and the Workers' Compensation Board. Providers who misrepresent their findings will have their WCB authorization revoked.

Opt-outs, second opinions

  • PPO shall make claimants aware of their right to opt-out of PPO care and seek medical treatment from outside the PPO. The right to opt-out is per injury.
  • The employee may seek medical treatment from a provider outside of the PPO network only after 30 days from the date of their initial visit to a PPO provider.
  • The employer has the right to require a second opinion from a provider within the PPO.
  • The PPO shall permit the claimant to choose treatment for occupational disease from the NYS Occupational Health Clinics Network.

Notice and approval required to discontinue operation

PPO shall provide at least 90 days written notice to each participating carrier or self-insured employer, the Commissioner of Health, and the Workers' Compensation Board Chair, before voluntarily discontinuing operations.

Responsibilities

Employer responsibilities

Where there is a duty to collectively bargain for the utilization of a PPO, an employer must engage in such bargaining and must file with the Workers' Compensation Board a notarized affirmation signed by the collective bargaining agent(s) confirming that the requisite negotiation 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.

Insurer responsibilities

All insurers (carriers and self-insured employers) who have contracted with PPOs for the treatment of workers' compensation injuries, shall report to the Chair of the Workers' Compensation Board, the names and addresses of insured employers who have elected to utilize the PPO and specified data pertaining to utilization, quality of care, costs and outcomes.

For information contact

Research and Data Analysis Bureau
Workers' Compensation Board
328 State Street
Schenectady NY 12305
MCNetworks@wcb.ny.gov

Employee responsibilities

Employees must seek initial treatment from the PPO and may opt-out only after 30 days from the initial visit.

Article 10-A Preferred Provider Organizations

Arrangements for Insurers

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
MCNetworks@wcb.ny.gov

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.

Article 10-A Preferred Provider Organizations

PPO- Employer Affirmation A

Arrangements for self-insurers

In accordance with Subpart 325-8 of Title 12 NYCRR, all self-insured employers 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 with respect to the employer and the preferred provider organization with which it has contracted.

Self-insurers who contract with a PPO are encouraged to use registration form to report the following information directly to the Workers' Compensation Board:

  • Name of employer (full legal name as well as DBA or AKA)
  • Address of employer
  • Name of certified PPO (full legal name as well as DBA or AKA)
  • Address of PPO
  • Union participation in PPO arrangement
  • Effective date of the program
  • Name and phone number for employer contact person

Employers which are members of group self-insurance plans must be listed individually, but the contact person may be the program administrator for the group.

Self-insurers are encouraged to report on the registration form the above-referenced information.

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 notarized affirmations shall be filed with the Workers' Compensation Board within ten days of the effective date of PPO participation.

Notarized affirmations may be delivered by mail, personal delivery or fax to:

Research and Data Analysis Bureau
Workers' Compensation Board
328 State Street
Schenectady NY 12305
MCNetworks@wcb.ny.gov

Please note that PPO participation will be jeopardized by failure to file the requisite information and notarized affirmations.

Any questions or concerns related to this matter may be directed to (877) 632-4996.

PPO Self-Insured Employer Registration Form

PPO - Employer Affirmation A

FAQs

General questions

  1. How can I set up a Preferred Provider Organization (PPO) network?

    To become a certified PPO in the State of New York, please contact the WC Program Director in the NYS Dept. of Health at (518) 474-5515.

  2. Where can I find a listing of PPO networks?

    View list of Active PPOs<

  3. What is the PPO program?

    The PPO (Preferred Provider Organization) program establishes procedures and protections governing the ability of an insurance carrier/TPA/Self-Insured employer to direct claimants to seek all medical services from a network of providers. This is in with accordance with Article 10A of the Workers Compensation Law, NYCRR Subpart 325-8 and NYCRR Title 10 Part 732 - these became effective on January 1st, 1997. The claimant is required to utilize the PPO network provider for the first initial visit. A claimant can wait 30 days after the initial visit to the PPO provider in order to opt‐out (written notification to employer/insurer). An employer/insurer can seek a second opinion from another PPO provider.

Injured worker questions

  1. My employer/insurer has signed up with a PPO. Should I use the PPO providers?

    Yes, if you have received written notification (an email, notice on employer website, letter or poster in your employer's break room or common room), you are required to seek treatment with any provider in the PPO network. If you do not use the PPO provider, the insurer could deny payment of your medical bill.

  2. What if I prefer my healthcare provider and do not want to use the PPO provider?

    You can choose to opt‐out of your employer's PPO provider network by notifying your employer in writing (simple letter specifying your intent to opt‐out of the PPO program). You will need to wait 30 days after the initial visit to the PPO provider to seek treatment from your preferred provider. The employer/insurer has the right to require that you seek a second opinion from another PPO provider.

  3. My employer/insurer has insisted that I sign a consent form. Is this allowed?

    This consent form is only used in conjunction with a Recommendation of Care (ROC) program. A consent form should only be signed at the time of injury. It should not be signed prior to an injury. The form is an acknowledgment that the claimant can receive medical services from an employer/insurer recommended provider network. By signing this consent form, the claimant is still able to utilize this recommended network or any other WC Board authorized provider.

Medical provider questions

  1. How can I join a PPO network?

    View list of Active PPOs and contact the identified PPO Administrators directly.

  2. I am health provider and my bill for services have been discounted. What should I do?

    An insurance carrier or self-insured employer can discount your bill if you have signed a business contract to accept a discounted fee schedule. This contract does not have to be with a certified PPO network entity. If you do not believe that you signed a contract, ask the employer/insurer or their bill review company to send you a copy of the contract.

  3. I am health provider and my bill for services have been discounted. I contacted the bill review company for a copy of the contract, but there has been no response.

    If the insurer/TPA or employer has not responded to your request for your provider contract, please file a Request for Decision on Unpaid Medical Bill(s) (Form HP-1.0) with the Board. You should also contact the claimant to file a Request for Assistance by Injured Worker (Form RFA-1W) on your behalf to schedule a Workers' Compensation Law Judge hearing.

  4. I am health provider and my bill for services have been discounted. I received a copy of an old contract signed many years ago. What should I do?

    If a contract exists whether old or not and you have not terminated your business arrangement to receive discounted fees for services related to NYS WC claims, you must accept the discounted fees for services previously rendered. To terminate this contract you must send a termination letter to the PPO.

  5. I am health provider and want to terminate my PPO contract. What happens to my patients?

    Insurers/TPA can restrict patients from receiving treatment from out-of-network providers. If a claimant would like to continue treatment from out-of-network providers, the claimant can opt‐out from the PPO network by notifying their employer/insurer/TPA in writing of this intent. The insurer/TPA can also seek a second opinion from another PPO network provider.

    Insurers/TPA can restrict patients from receiving treatment from out-of-network providers. If a claimant would like to continue treatment from out-of-network providers, the claimant can opt‐out from the PPO network by notifying their employer/insurer/TPA in writing of this intent. The insurer/TPA can also seek a second opinion from another PPO network provider.

  6. I am a health provider and was notified by the insurer that my patient has to seek treatment from a PPO provider. Can the insurer do this?

    Yes, if the patient's employer/insurer has a PPO contract, the patient is required to use the PPO provider network. This is in accordance with the PPO rules and regulations effective from January 1st, 1997.

  7. I am a health provider and my patient has indicated a desire to seek treatment from me instead of a PPO provider. What can I do?

    The claimant has a right to opt-out of the PPO program. The claimant must notify their employer/insurer/TPA in writing of this intent. The insurer/TPA can also seek a second opinion from another PPO network provider.

Insurance carrier/third-party administrator(TPA)/self-insured employer questions

  1. What are the reporting requirements of the PPO program?

    All insurance carriers and self-insured employees who have contracted with a PPO for medical services shall report to the Chair the names and addresses of the insured employers who have elected to utilize the PPO. Insurance carrier and self-insured shall also report to the Chair, in a prescribed format specified data relating to utilization, quality of care, costs and outcomes. Please email MCNetworks@wcb.ny.gov for questions.

  2. What is an endorsement notice and when should it be filed?

    Insurance carriers shall submit to the Board a copy of the New York Compensation Insurance Rating Board's PPO Endorsement (WC 31 06 16) or the New York PPO Premium Endorsement (WC 31 04 03) for each employer electing to utilize a New York certified PPO (see PPO Arrangements for Insurance Carriers link). This notice should filed within 10 days of the effective date of PPO participation or whenever there is premium renewal. The endorsement copies can be emailed to MCNetworks@wcb.ny.gov.

  3. What is an affirmation notice and when should it be filed?

    Subpart 325-8 of Title 12 NYCRR requires that an employer should submit a notarized affirmation signed by any collective bargaining agent(s) confirming PPO participation. This notice should filed within 10 days of the effective date of PPO participation or whenever the collective bargaining contract is renewed. The affirmation copies can be emailed to MCNetworks@wcb.ny.gov.

  4. Do self-insured employers have to file the endorsement notice and the affirmation notice?

    Self-insured employers do not need to file the endorsement notices. However, a self-insured employer will need to file the registration form found on the Board website - follow the Preferred Provider Organization Arrangements for Self-Insurers link. Subpart 325-8 of Title 12 NYCRR requires that a self-insured employer should submit a notarized affirmation signed by any collective bargaining agent(s) confirming PPO participation. This notice should filed within 10 days of the effective date of PPO participation or whenever the collective bargaining contract is renewed. The affirmation copies can be emailed to MCNetworks@wcb.ny.gov.

Resource

Did you find this page helpful?