N.Y. Comp. Codes R. & Regs. tit. 12 § 324.1

Current through Register Vol. 46, No. 45, November 2, 2024

Section 324.1 - Definitions

For purposes of this Subchapter:

(a) The definitions of the terms in section 300.1(a) of this Title are applicable to this Subchapter.

(b)Calendar day means the time period from midnight to midnight. For the purposes of calculating calendar days, the day of submission is day zero and the first calendar day begins at midnight following the submission.

(c) Carrier's Physician means a physician or physicians, licensed by New York State, or the appropriate state where the professional practices, who is:

1. employed or contracted by the insurance carrier, self-insured employer, or third-party administrator; or

2. employed by a URAC accredited company retained by the insurance carrier, self-insured employer, or third-party administrator through a contract to review prior authorization requests and advise the insurance carrier, self-insured employer, or third-party administrator; and

3. is not employed or contracted by the carrier, self-insured employer, or third-party administrator's recommendation of care network.

(d)Consistent with the Medical Treatment Guidelines means within the criteria of the Medical Treatment Guidelines and based on a correct application of the Medical Treatment Guidelines.

(e)Denial, deny or denies means a denial or a partial approval by an insurance carrier, self-insured employer, or third-party administrator of a Prior Approval Request, defined herein, made pursuant to section 324.3 of this Part or a prior approval request made pursuant to section 324.4 of this Part.

(f)Maximum Medical Improvement (MMI) means a medical judgment that

(1) a claimant has recovered from the work injury to the greatest extent that is expected and

(2) no further improvement in his or her condition is reasonably expected. The need for palliative or symptomatic treatment does not preclude a finding of MMI. In cases that do not involve surgery or fractures, MMI cannot be determined prior to six months from the date of injury or disablement, unless otherwise agreed to by the parties.

A finding of maximum medical improvement is a normal precondition for determining the permanent disability level of a claimant.

(g)Medical Director's Office means the Medical Director of the Board, the Executive Medical Policy Director, the Assistant Medical Director of the Board, or their designee.

(h)Medical care means all care, treatment, and other attendance for an injured worker's injury, illness or occupational disease as listed and provided in Workers' Compensation Law Sections 13, 13-b, 13-k, 13-l, and 13-m.

(i)Medical Treatment Guidelines means the treatment guidelines for workers' compensation injuries, illnesses, or occupational diseases to the parts of the body addressed in the guidelines incorporated by reference in section 324.2(a) of this Part.

(j)Prior Authorization means the carrier, self-insured employer, or third-party administrator's approval of a Prior Authorization request initiated by the medical provider.

(k)Carrier's physician's medical report means the evaluation of a claimant without physical examination, by the Carrier's physician, based on the review of reports and records, including treatment notes, diagnostic test results, depositions or hearing testimony, exhibits, and other records or reports from medical providers or independent medical examiners or both in the electronic case file maintained by the Board.

(l)Prior Authorization Request (PAR) shall mean any of the following: a variance request (PAR: MTG Variance) or a request for special services (PAR: Special Services) made pursuant to section 324.3 herein, or a request confirming consistency with Medical Treatment Guidelines (PAR: MTG Confirmation) or confirming medical necessity when there is no Medical Treatment Guideline that addresses treatment for the body part or condition and the treatment costs less than $1000 ( PAR: Non-MTG $1,000 or Under) as defined in 324.4. "Prior Authorization Request" or "PAR" may also mean a prior authorization request for medical care costing more than $1000 when there is no Medical Treatment Guideline that addresses treatment for the body part or condition (PAR: Non-MTG Over $1,000) made pursuant to section 325-1.4 of this Chapter.

(m)Treating medical provider means a duly licensed acupuncturist, chiropractor, nurse practitioner, occupational therapist, physical therapist, physician, physician assistant, podiatrist, psychologist, or social worker authorized by the chair, as such terms are defined in section 13-b of the workers' compensation law, or any provider not permitted to obtain authorization in New York State and who has not surrendered or had a Board authorization suspended or revoked, and (1) is licensed pursuant to the education law to provide medical care and treatment in the state of New York, or (2) is duly licensed pursuant to the laws of another state to provide medical care and treatment, who is providing treatment and care to an injured worker pursuant to the Workers' Compensation Law.

N.Y. Comp. Codes R. & Regs. Tit. 12 § 324.1

Amended New York State Register September 11, 2019/Volume XLI, Issue 37, eff. 9/11/2019

Amended New York State Register March 3, 2021/Volume XLIII, Issue 09, eff. 6/7/2021