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CMS-1500 electronic submission is mandatory

Occupational Therapists

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Overview

Occupational therapists (OTs) can play an important role in helping New Yorkers recover from work-related injuries and illnesses.

To treat injured workers in the NYS workers' compensation system, OTs must be authorized by the Board. Treatment of an injured worker also requires referral from the treating physician, physician assistant, podiatrist, or nurse practitioner. Read on to learn more.

Looking for a Board-authorized occupational therapist or other health care provider? Use the Health Care Provider and IME search.

Board authorization

Occupational therapists must be authorized by the NYS Workers' Compensation Board to treat injured/ill workers. As of January 1, 2020, all providers who can be authorized must be authorized to treat injured workers. Learn how to get authorized.

A Board-authorized OT can:

  • Treat patients with work-related injuries or conditions.

Board-authorized OTs cannot:

  • Perform Independent Medical Examinations (IMEs), which are consultations to help resolve disputes in workers' compensation cases, usually at the request of the insurance carrier
  • Comment on causality of the injury or illness or give an opinion on the degree of temporary impairment. (Such would not be considered medical evidence in a workers' compensation case.)

Treatment

To treat an injured worker, occupational therapists need a referral from the treating medical provider. This referral can be from a Board-authorized physician, physician assistant, nurse practitioner, or podiatrist.

Treatment of workers' compensation patients follows standards of care set forth in the New York Medical Treatment Guidelines (MTGs). There are currently 16 MTGs that address the most common injuries and illnesses within the workers' compensation system. Providers have access to an easy-to-use online MTG Lookup tool to check treatment protocols.

Health care providers who wish to provide treatment and medication that fall outside of the MTGs must obtain prior authorization. Health care providers can submit (and check the status of) prior authorization requests (PARs) using the Board's online system, OnBoard.

See: Medical Treatment Guidelines; OnBoard

Telehealth

Under NYS Workers' Compensation rules, occupational therapy services must be provided in person and cannot be delivered via telehealth.

PARs through OnBoard

A PAR is a request by an injured worker's health care provider to obtain prior approval from the claim administrator (e.g., insurance carrier) to cover costs associated with a specific treatment under workers' compensation insurance. There are several categories of treatment that require prior authorization.

Providers must submit all PARs through OnBoard, the Board's online system. OnBoard automatically routes the request to the appropriate claim administrator for review, and providers can track the status of the PAR through their OnBoard dashboard.

Occupational Therapists are eligible to submit the following types of PARs:

  • Non-MTG over $1,000 - request for treatments/tests costing more than $1,000 with no applicable MTGs; replaces Attending Doctor's Request for Authorization and Carrier's Response (Form C-4AUTH)
  • Non-MTG under or = $1,000 - requests for treatment/test costing $1,000 or less with no applicable MTGs.

To learn more about OnBoard and access training on submitting PARs, please visit the OnBoard section of this website.

Billing

Reimbursement for services performed by Board-authorized OTs will be paid in accordance with the NYS Workers' Compensation Acupuncture and Physical & Occupational Therapy Fee Schedule. Providers may purchase the fee schedule from RefMed or view in person by appointment at the locations listed in the Where to view section of the Board's Medical Fee Schedules page.

Occupational Therapists and all providers who bill for services in treating injured workers must use the CMS-1500 universal billing form with an accompanying medical narrative. Unlike other medical providers who can comment on causality of the injury or illness, or give an opinion on the degree of temporary impairment, OTs may only comment on work status (whether the patient is currently working) within their medical reports. Their record, report or opinion may not be considered as evidence of the causal relationship or temporary impairment percentage. The bill and medical report must be submitted electronically through a Board-approved electronic submission partner, otherwise the Board will not enforce payment. Visit the CMS-1500 Initiative webpage for information and resources related to the CMS-1500 universal billing form and electronic submission mandate.

Resources

Here are some helpful resources for health care providers in the NYS workers' compensation system.

  • Health care provider webpage: a section of the Board's website specifically for health care providers.
  • Provider Toolkit: important resources, requirements, and updates for treating health care providers to be aware of regarding the workers' compensation system.
  • Training: courses, by topic, including the New York Medical Treatment Guidelines, New York's mandatory standard of care for treatment in the workers' compensation system.
  • OnBoard overview: an introduction to the Board's online system that health care providers use to submit and check the status of prior authorization requests (PARs) for medical treatment and submit requests for review of medical billing disputes.
  • Webinars: the Board regularly hosts webinars for health care providers and other stakeholders, and recordings are posted online. See the Recorded Webinars page to view past webinars or the Upcoming Webinars page to register for a future event.

To get a basic understanding of workers' compensation, it's recommended to view or attend a Workers' Compensation 101 webinar, hosted by the Board's Advocate for Injured Workers.

Contact the MDO

The Board has a Medical Director's Office, who has staff available to answer your questions about treating in the New York State workers' compensation system. You can contact the Medical Director's Office at MDO@wcb.ny.gov or by calling (800) 781-2362.

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