Training: Health Care Providers
A Durable Medical Equipment (DME) prior authorization request (PAR) will be required prior to prescribing DME items that are not included, or have "Yes" in the PAR Required column, on the DME Fee Schedule.
Learn more about the Official New York Workers' Compensation Durable Medical Equipment Fee Schedule (DME Fee Schedule).
Drafting/Submitting a DME PAR
Provider delegates can draft a PAR to be reviewed and submitted by the health care provider. To learn more about the role of the provider delegate, visit the Medical Portal Access and Administration: Health Care Providers page.
Health care providers are required to submit the PAR, whether drafted by themselves or drafted by their delegates. Any PAR drafted by a delegate will appear on the health care provider's Draft eForms tab for final submission.
To submit or draft a DME PAR, select the Submit a Request button on the top right of your dashboard.
Select Prior Authorization (PAR).
A provider's name will be selected automatically if they are submitting on their own behalf, or if a user is only delegated to draft requests on behalf of one health care provider. If a delegated user drafts requests for multiple providers, they must select the provider's name from a list of providers.
If the provider only has one medical license, the form will automatically fill in the license information. If there is more than one medical license, select the correct license from the drop-down list.
Select the Claim Search button.
After conducting the Claim Search, select the Durable Medical Equipment PAR category.
Complete the additional fields that appear for a DME PAR.
Begin typing at least three characters of the Healthcare Common Procedure Coding System (HCPCS) Code or description in the HCPCS Code/Description field and then select the correct HCPCS Code from the list.
- Select the MTG Site from the drop-down options. If there is no MTG site associated with the PAR, select None.
- Begin typing at least three characters of the Medical Treatment Guide Reference and then select the correct reference from the list.
- Enter the Body Part.
- Select the Side of Body, if applicable.
After the information is entered, select Save.
The DME PAR item is now added.
If multiple DME items are being requested for the patient, they can be added by selecting the Add Another Item button and selecting Durable Medical Equipment, then completing the necessary information for that DME item. All DME requests will be processed as a single PAR.
If there is a different PAR needed, you may also add it by selecting the Add Another Item button and selecting the appropriate PAR type. You will be prompted to complete and submit additional PARs as separate PARs once the DME PAR has been submitted.
If you need to change any information previously entered, select the edit button. If you do not want to submit a request for a DME item, you may remove it. Once you move to the next screen to complete the request, you will not be able to make changes to the request details.
Select the Complete Request(s) button to continue entering information for the first DME PAR.
You can save as a draft by selecting the Save as Draft button on the top right of the page. Your draft will be saved under the Draft eForms tab in your dashboard, where you will be able to select it and continue completing the request at a later time. If you entered information for multiple PAR types, each PAR will be saved as a separate entry in the Draft eForm queue.
Draft eForms are removed if they are not submitted within 30 days from the date they are created.
Select the Add Details button to enter additional details for your DME request.
Select Save Details.
Select Medical Necessity / Supporting Medical.
Statement of Medical Necessity
Enter or upload a document providing all relevant clinical information to support the request. Include narrative(s), progress notes and other supporting documentation (e.g., symptoms, surgery date if applicable, justification for the equipment, etc.), any contraindications, and if applicable, evaluation of efficacy to continue or extend the use of the requested durable medical equipment.
To upload a document:
Select Upload Relevant Clinical Information
Select Browse to locate the document on your computer
- Enter a Description of the document, if necessary.
- Select the Upload button to upload the document
You should receive a confirmation that the document was uploaded successfully. If there are more documents to add to your request, select Upload Additional Documents.
Select the Review and Submit button.
Review and Submit
Review all details to confirm the accuracy of your request. Select the Preview button to view the entirety of your PAR in a generated document.
If you are a delegated user drafting the PAR on behalf of a health care provider, select the Ready to Submit button. This will add the PAR to both the delegated user’s and the health care provider’s Draft eForms queue with a status of “ready to submit.” The health care provider must complete the process by signing and submitting the PAR. Drafted eForms will automatically be removed from the system after 30 days if they are not submitted.
If more than one PAR type was requested, you will be presented with the next PAR type to complete the details for that PAR. Each PAR will appear as a separate entry in the Draft eForms queue for both the delegated user and the provider.
Select Finish when done.
Health Care Provider
If you are the health care provider, select the Attest and Submit button. Provider delegates cannot attest to or submit the PAR.
If a delegate created the PAR on your behalf, open the PAR from your Draft eForms queue and review the PAR details. You may change the Request Details and Statement of Medical Necessity or upload different/additional documents, if necessary, before selecting the Attest and Submit button.
As the health care provider, you are required to understand all aspects of the attestation presented to you before submitting a PAR. Read the Attestation and Submission carefully, and then select Submit.
A confirmation page will show, confirming your DME PAR submission, which includes the time frame for an expected response.
After the PAR is submitted by the health care provider, the drafted PAR for a delegated user and the provider will be moved from the Draft eForms tab to both the Submitted eForms tab and the Prior Auth Active tab.
Prior Auth > Active Tab
Within your dashboard, you can view the recently submitted item in the Prior Auth > Active tab. The Due Date column will update with the date the claim administrator is required to respond. All time frames for claim administrator review and response are automatically tracked by the system. If the claim administrator does not respond within the designated time frame, an Order of the Chair may be issued.
The Current Activity tab will show the level of review of the request. An initial submission will be "Insurer Level 1 Review."
Submitted eForms Tab
The submitted PAR will also appear in the Submitted eForms tab. The Status column confirms that the PAR submission has been completed.
Prior Auth Resolved Tab
When a final determination is made on a PAR, it will be moved to the Resolved queue. When a PAR contains multiple requests, it will reach final determination once all request items in the PAR have reached a final determination. For example, if one DME request is granted and the other DME request is denied at the level 1 review, both requests will move to level 2 review and if escalated by the health care provider, to level 3 review (Board’s Medical Director’s Office) together. Once all requests within the PAR have received a final determination, the PAR will moved to the Resolved tab of the dashboard. It is recommended to check your Resolved tab for final decisions daily.
When the claim administrator's reviewer responds to your request:
- The Active tab on the dashboard will update with the new information and show in bold letters.
- The provider and any delegates will get an email or text message, based on their notification preferences in the OnBoard user's profile, advising that action was taken on their request.
- If the claim administrator needs more information to respond to the request, they may send a request for further information.
- If the PAR was granted by the claim administrator, or the Board's Medical Director's Office issues a Notice of Decision, the PAR will appear on the Resolved tab. It is recommended that the Resolved tab be checked at least daily for final decisions made on PARs.
- If any other action is taken on a PAR, it will remain on the Active tab and the Current Activity column will show the current status.
To review the response from the claim administrator, select the PAR ID link to access the PAR Details page. In the Request Details section on the PAR Details page, select the Level 1 or Level 2 Insurer Response Details as appropriate to view the full response details.
DME PARs Escalated to Level 2 Review
DME PARs that are granted in part or denied for medical reasons at the Level 1 review will automatically be escalated to a Level 2 review.
The Current Activity column on the Active tab will show Insurer Level 2 Review, indicating the PAR has been automatically escalated. This review must be done by the claim administrator within the required time frame, shown in the Due Date column.
In this example, the Current Activity column shows the DME PAR is currently in an Insurer Level 2 Review status.
If the Level 2 reviewer grants the request, it will appear on the Prior Auth > Resolved tab
Escalating DME PARs to Level 3 Review
DME PARs that are granted in part or denied for medical reasons at the Level 2 review will not automatically be escalated for a Level 3 review by the Medical Director’s Office (MDO). After the Level 2 reviewer has submitted their denial or grant in part of the DME PAR, the PAR item will update, in bold, in the Active tab. The Current Activity column will show the latest response. Escalating to a Level 3 review needs to be completed within the required time frame indicated in the Due Date column.
In the example below, the Current Activity is Review Insurer Level 2 Denial and may be escalated for Level 3 Review by 10/28/2021.
To escalate to Level 3 review, select the PAR ID in that item’s row. Select the Actions button on the top right of the PAR Details page and select Request L3 Review.
Select the item(s) you would like to escalate, enter the reason for the Level 3 escalation in the text box, and select Submit.
The escalation to Level 3 will now appear in your Submitted eForms tab. The eForm Name will show the PAR type and the level of request. The Status column clarifies that the escalation is complete.
Level 3 Response
The Board’s MDO will issue a Notice of Resolution. The determination by the MDO on the medical necessity of the DME request is final.
The PAR will be moved from the Prior Auth Active tab to the Resolved tab, and will no longer appear in the Active tab. It is recommended to check your Resolved tab for final decisions daily.
Selecting the PAR ID link will open the PAR Details page. You will be able to view, download or print the Notice of Resolution from the Documents section on this page.