NYS Workers' Compensation Fundamentals for Health Care Providers

Overview

The Board has curated the following trainings and resources to help providers understand key aspects about treating patients in the workers' compensation system.

To apply for Board-authorization to treat injured workers, health care providers:

• First: review the training topics and the summary of your obligations as a Board-authorized health care provider on this page (below).
• Then: complete the online application. This includes attesting that you have reviewed the trainings and summary of your obligations as a treating provider.

Training

To review these brief trainings and resources, click on the title of each topic.

Understanding your obligations

Before becoming authorized, health care providers must review a summary of their obligations as a health care provider authorized to provide services to injured workers in the New York State workers' compensation system, as detailed below.

Authorization to treat injured workers

You may not treat injured workers or perform independent medical examinations without authorization by the Board. Section 13-b of the New York State Workers' Compensation Law states, in part: "No person shall render medical care or conduct independent medical examinations under this chapter without such authorization by the chair."

However, 13-b allows for the following exceptions:

• Any provider licensed to provide medical care and treatment in the state of New York, pursuant to the Education Law, may render emergency care and treatment in an emergency hospital or urgent care setting providing emergency treatment.
• The licensed provider may continue such medical care under this chapter while an injured employee remains a patient in such hospital or urgent care setting.
• Under the direct supervision of an authorized provider, medical care may be rendered by a registered nurse or other person trained in laboratory or diagnostic techniques within the scope of such person's specialized training and qualifications.

General obligation to provide services

You must provide necessary treatment to your workers' compensation patients within your normal scope of practice. If you are accepting new patients, you must accept new workers' compensation patients as well, and you may not treat injured workers differently than other patients in your practice.

With respect to treating injured workers, 12 NYCRR § 325-1.21 states, in part, that you must render treatment and care to injured employees under the Workers' Compensation Law and accept/treat such injured workers in a manner corresponding to that accorded other patients in your practice, without discriminating against such injured workers because they are or may be covered by the provisions of the Workers' Compensation Law.

Furthermore, you must provide necessary treatment during the pendency of a case. You may not deny treatment because a prospective patient does not yet have a WCB case number or because a legal issue is outstanding in a prospective patient's case.

Ongoing requirements

Once authorized, you will be required to renew your authorization at intervals which coincide with the renewal of your professional license. A failure to renew will result in the removal of your authorization to treat injured workers and/or perform independent medical examinations. You will be responsible for keeping your practice and mailing/email addresses, telephone/fax numbers up to date via the renewal form.

You will also be responsible for the following:

• Maintaining your professional license.
• You will lose your authorization to treat injured workers if there is a lapse of more than 30 days in your license registration.
• Any disciplinary action taken by the New York State Department of Health, the New York State Education Department, or another regulatory agency may result in the Board taking action, including suspending or revoking your authorization to treat injured workers or to perform independent medical examinations.
• Notifying the Board of changes in board-certification status.
  • Physicians certified by a member board of the American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) must notify the Board of any changes to their certification status. Continuous ABMS or AOA certification is required for physicians' authorization to perform independent medical examinations.
  • Acupuncturists certified by the National Certification Commission for Acupuncture and Oriental Medicine must notify the Board of any changes to their certification status.

Billing and medical narrative requirements

Employers in New York State are required to have insurance to cover indemnity and health care benefits for workers who are injured on the job.

After providing treatment, you will bill the appropriate insurer using the CMS-1500 universal billing form, which must be accompanied by a medical narrative. The CMS-1500 form and medical narrative must be submitted electronically through a Board-approved electronic submission partner (clearinghouse). The listing of Board-approved electronic submission partners is published on the Board's website. Some accept paper CMS-1500 forms and convert them; others require electronic formats. Health care providers can choose the electronic submission partner that will work best for them.

After treating an injured worker, providers will submit their bill and narrative attachment to the electronic submission partner they have a relationship with, in the agreed-upon format. The electronic submission partner will forward the bill and narrative attachment to the appropriate workers' compensation payer and send a copy to the Board. The information will be used as evidence in your patient's case.

You must abide by the following time frames for submitting medical reports to the Board and the payer (set forth in NYCRR 325-1.3):

• Initial report: within 48 hours of first treatment
• Subsequent reports: 15 days after first treatment, and thereafter for continuing treatment: after each follow-up visit scheduled when medically necessary, and visits must take place at least every 90 days if the patient is receiving lost wage benefits.

Your CMS-1500 must include a medical narrative attachment with three mandatory elements:

• The patient's work status
• Causal relationship of the injury to the patient's work activities (for those provider types permitted to provide opinions on causal relationship)
• Temporary impairment percentage (for those provider types permitted to provide opinions on causal relationship)

You may use a narrative report template to document the three mandatory elements. Detailed requirements are available on the CMS-1500 section of our website. If you use your own report template, the three mandatory elements should appear prominently (e.g., typically at the very beginning or very end of your clinic documentation).

Maximum medical improvement and permanent impairment

Should you conclude that your patient has reached maximum medical improvement or is permanently impaired as a result of their work-related injury, you must document this opinion using the Doctor's Report of MMI/Permanent Partial Impairment (Form C-4.3). You must respond promptly to any request from the Board to complete and submit this form. The C-4.3 form should be submitted electronically through a Board-authorized electronic submission partner along with the associated CMS-1500 medical bill.

In addition to the form's general sections A-E, Attachment A (C-4.3A) should be completed for a Schedule Loss of Use (SLU) and Attachment B (C-4.3B) for a Non-Schedule Loss (NSL, also known as a classification.) Instructions for completing an SLU and/or an NSL evaluation can be found in the Board's two volume set of Impairment Guidelines.

The 2012 guidelines, New York State Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity, should be used for NSL evaluations. The 2018 guidelines, Workers' Compensation Guidelines for Determining Impairment, should be used for SLU evaluations. Both sets of Impairment Guidelines and their corresponding forms are available on the Board's website.

Medical fee schedule

Fees for services may not exceed those outlined in the Official New York Workers' Compensation Medical Fee Schedule. You must bill with CPT codes selected from the fee schedule. Each CPT code has a relative value which is multiplied by a conversion factor for care type and geographical region to determine the correct price. Additional rules apply for certain services. Your bills must conform to the fee schedule.

The Official New York Workers' Compensation Medical Fee Schedule may be purchased from RefMed by calling (863) 222-4071, or by visiting RefMed, keyword "New York."

The Fee Schedule may also be examined at the Office of the Department of State, 162 Washington Ave., Albany, NY 12231, the Legislative Library, the libraries of the New York State Supreme Court, and at Workers' Compensation Board District Offices. For more information, see the Board's Medical Fee Schedules webpage.

Section 13-f of the New York State Workers' Compensation law

Section 13-f states, in part: "no provider of health care rendering medical care or treatment to a compensation claimant, shall collect or receive a fee from such claimant within this state, but shall have recourse for payment of services rendered only to the employer..."

You may not solicit or accept a fee from an injured worker for services relating to their on-the-job injury, nor may you solicit or accept a fee from the patient's private insurer. Billing the patient directly for these services is misconduct and may result in disciplinary action, including the suspension or revocation of your authorization to treat injured workers, and a referral to the Office of Professional Conduct or Office of the Professions for additional disciplinary action.

Furthermore, you may not solicit or accept a fee from an injured worker during the pendency of a case. You must abide by Section 13-f regardless of whether your patient has been assigned a Workers' Compensation Board case number or whether a legal issue is outstanding in the patient's case.

Testimony

You may be required to testify in your patient's workers' compensation case, for which you will be compensated pursuant to the Board's regulations. This is typically conducted through virtual depositions/hearings. If you fail to testify, it may adversely affect the injured worker's case, and you may face administrative action.

Medical treatment guidelines

The Board's New York Medical Treatment Guidelines (MTGs) are the standard of care for treating individuals with work-related injuries and illnesses in New York State and are based on the best available medical evidence and the consensus of experienced medical professionals. Treatment must conform to these guidelines.

Prior authorization

You must request prior authorization for certain services.

A prior authorization request is submitted to 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.

• Medication: Request for non-Formulary medications, including medical marijuana.
• MTG Confirmation: Confirmation that the proposed treatment or test is based on a correct application of the MTGs. Submission of MTG Confirmation is optional for health care providers, but response is mandatory for claim administrators.
• MTG Variance: Request for treatments or tests that vary from the Medical Treatment Guidelines.
• Non-MTG Over $1,000: Request for treatments or tests costing more than $1,000 with no applicable MTGs.
• Non-MTG Under or = $1,000: Requests for treatment or tests costing $1,000 or less with no applicable MTGs.
• MTG Special Services: Request for special services as required per the Medical Treatment Guidelines.
• 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."

The Board will not enforce payment for services which do not conform to the MTGs or for which approval has not been granted via the prior authorization process. A failure to abide by the MTGs, or to use the prior authorization process, may be considered misconduct and may lead to disciplinary action, including the suspension or revocation of your authorization to treat injured workers, and a referral to the Office of Professional Conduct or Office of the Professions for additional disciplinary action.

Prior authorization requests must be submitted through OnBoard, an online interface which facilitates the efficient processing of these requests as well as the submission of requests for resolving billing disputes.

Correspondence from the Board

You must respond promptly to any correspondence from the Board's Medical Director's Office, Office of General Counsel, or any other bureau or department of the Board, when such correspondence directs you to respond. A failure to respond to such correspondence may be considered misconduct and may lead to disciplinary action, including the suspension or revocation of your authorization to treat injured workers, and a referral to the Office of Professional Conduct or Office of the Professions for additional disciplinary action.

Resigning your authorization to treat injured workers

If you are authorized by the NYS Workers' Compensation Board to treat injured workers, and you wish to cease treating injured workers, you must submit a signed letter of resignation to the Board, as well as a transition plan to ensure continuity of care for injured workers you are treating. The transition plan must list all injured workers under your care, together with the authorized provider(s) who will be assuming the injured workers' care. This transition plan must include the following:

• Injured worker's name
• Injured worker's address
• Employer
• Date of accident
• WCB case number
• Insurer and insurer case number
• Name of the provider with similar specialty and credentials who will be continuing injured worker's care

You must send your resignation letter and transition plan to the Board's Medical Director's Office (MDO) at the address below at least thirty (30) days before the effective date of your resignation. Whenever feasible, you are encouraged to notify the MDO and initiate a transition plan at least ninety (90) days prior to your resignation date. If you fail to provide a transition plan, you may be referred to the Office of Professional Medical Conduct or Office of the Professions, as appropriate, for investigation of potential professional misconduct.

New York State Workers' Compensation Board
Medical Director's Office
150 Broadway, Suite 195
Menands, NY 12204

The resignation letter and transition plan may also be emailed to provider@wcb.ny.gov

Important: When you attest to having reviewed the training and summary of obligations on your application to become a Board-authorized provider, you agree to adhere to the requirements of the Workers' Compensation Law and Board rules when treating pursuant to your Board authorization.

Ready for the online application?

Once you've finished your review of the training topics and summary of your obligations, you can complete the online application for authorization.

Additional resources

In addition to the information provided above, which providers review prior to applying for authorization, there are other helpful resources for health care providers:

• Health care provider toolkit - a summary of what participating providers need to know, along with regular updates.
• Health care provider section of the Board's website
• Medical Fee Schedule section of the Board's website
• Medical Treatment Guidelines
• Deeper Dive: Medical Treatment Guidelines Training (with and without CME credit)
• Deeper Dive: Impairment Guidelines Training

Health care providers are also encouraged to subscribe for text or email Board notifications to receive news on regulations, process updates, training opportunities, and more. Visit Email/SMS Updates to subscribe to any topics of interest.

Contact the Medical Director's Office (MDO)

If you have a question for the MDO, you can quickly reach us via:

• Helpline: (800) 781-2362
• Email: MDO@wcb.ny.gov