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CMS-1500 electronic submission is mandatory

Physician Assistants

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Overview

Physician assistants (PAs) 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, physician assistants must be authorized by the Board. Physician assistants must identify an authorized supervising physician upon applying for authorization to treat injured workers. Read on to learn more.

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

Board authorization

Physician assistants 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 PA can:

  • Treat workers' compensation patients under the treating provider's supervision.
  • Determine a patient's ongoing level of disability.

Board-authorized PAs 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.

Treatment

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.

The New York Workers' Compensation Drug Formulary (Drug Formulary) lists the medications that can be prescribed to treat injured workers, consistent with the MTGs.

Health care providers who wish to provide treatment and medication that fall outside of the MTGs and Drug Formulary 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; New York Workers' Compensation Drug Formulary; OnBoard

Telehealth

Physician Assistants may treat via telehealth within proper context and timing within the following restrictions:

  • Initial visit: The first visit with a treating provider must be in-person
  • Acute and subacute phases of injury or illness: Within the first three months following the date of injury or illness, use of telehealth is at the clinical discretion of the treating provider. However, the treating provider must conduct an in-person assessment at least every third visit.
  • Chronic phase of injury or illness: When more than three months has passed from the date of injury or illness, use of telehealth is at the clinical discretion of the treating provider. However, the treating provider must conduct an in-person assessment no less than every three months.
  • Injury or illness at maximum medical improvement: When an injured worker is in the chronic phase of injury or illness and the treating provider believes they have reached maximum medical improvement (MMI), meaning their impairment or disability status is permanent and unlikely to change, use of telehealth is at the discretion of the treating provider. However, the treating provider must conduct an in-person assessment at least annually.

Within those parameters and restrictions, there are certain treatment situations when an in-person examination may not be necessary, such as:

  • Routine follow-up visits after comprehensive initial in-person exam
  • Discussions of test results/counseling on clinical options
  • Consultations about prescriptions
  • Nutritional counseling
  • Dermatology appointments without procedures

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.

Physician assistants are eligible to submit the following types of PARs:

  • Medication - request for non-Formulary medication(s), including medical marijuana.
  • MTG confirmation - confirmation that the proposed treatment(s)/test(s) are based on a correct application of the New York Medical Treatment Guidelines (MTGs); replaces Attending Doctor's Request for Optional Prior Approval and Carrier's/Employer's Response (Form MG-1). Submission of MTG confirmation is optional for health care providers, but response is mandatory for claim administrators.
  • MTG variance - request for treatments/tests that vary from the MTGs; replaces Attending Doctor's Request for Approval of Variance and Carrier's Response (Form MG-2).
  • 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.
  • Durable medical equipment (DME) - request for DME not on the Official New York Workers' Compensation durable medical equipment (DME) Fee Schedule or for an item on the fee schedule that requires prior authorization., with the designation of "PAR."

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 PAs is paid in accordance with the New York Workers' Compensation Medical 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.

PAs and all providers who bill for services in treating injured workers must use the CMS-1500 universal billing form with an accompanying medical narrative. Physician Assistants may comment on temporary impairment percentage (under a physician's direct supervision) and work status, but not on causal relationship. Their opinions are not considered evidence of a causal relationship or the degree of disability. 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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