N.Y. Comp. Codes R. & Regs. Tit. 12 §§ 325-7.3

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

Section 325-7.3 - Requirements to be a diagnostic testing network

(a) A diagnostic testing network must be legally and properly organized as defined in section 325-7.1(j) of this Subpart.

(b) Any diagnostic testing network that contracts or has an agreement with an insurance carrier pursuant to Workers' Compensation Law section 13-a(7) and this Subpart must file with the chair within 30 days after the effective date of this Subpart or 30 days before any diagnostic examinations and tests of claimants are scheduled:

(1) copies of the basic organizational documents of the diagnostic testing network, along with proof that those documents which must be filed with the Secretary of State have been so filed, such as the certificate of incorporation, bylaws, articles of organization, partnership agreement, trust agreement, operating agreement or other applicable documents and agreements, and all amendments thereto;

(2) the name or names under which it is registered with the Department of State;

(3) the name or names under which it conducts business;

(4) the address or addresses of its administrative office and each of the offices where it conducts any business;

(5) the telephone numbers of each administrative office and business location;

(6) the network's, as well as any affiliated network provider's, tax identification number;

(7) the name, title, and telephone number of the contact person for the network;

(8) a list of the names, addresses, telephone numbers, and official positions of the members of the board of directors, members or managers of a limited liability company, officers, controlling persons, owners or partners and medical director of the diagnostic testing network, updated annually;

(9) a copy of the proposed contract, form of contract or any memorandum of understanding between the parties, and all attachments thereto, to be made with affiliated network providers and any changes or amendments thereto, which shall include:

(i) provisions allowing access by the diagnostic testing network to the test results, reports and records of the affiliated network providers;

(ii) provisions requiring affiliated network providers to seek consent from the claimant at the time diagnostic examinations and tests are performed;

(iii) provisions requiring all affiliated medical providers practicing in New York State to be authorized by the chair to treat injured workers;

(iv) provisions setting forth the process to address complaints by treating medical providers regarding the readability of the diagnostic examinations and tests;

(10) a copy of the proposed agreement, contract or form of contract, and all attachments thereto, to be made between the diagnostic testing network and any insurance carrier;

(11) a description of the services provided by the network and its affiliated network providers, including a description of the relationship between the network and its owners, officers, or partners and the affiliated network providers;

(12) a description of the proposed service area and any changes thereto;

(13) a list of the names and physical addresses of the medical facility or professional office location(s) where diagnostic examinations and tests will be performed;

(14) a description of the diagnostic examinations and tests offered at each medical facility or professional office location listed in paragraph (13) of this subdivision, and the web address where a complete list of such diagnostic examinations and tests may be located;

(15) a list of the names, addresses, and board authorization numbers, for those practicing in New York State, of the medical providers who may perform and/or interpret the diagnostic examinations and tests at each listed location;

(16) a description of any quality assurance program and any quality assessment and performance improvement plan, along with any documentation about such program and plan; and

(17) a description of the process affiliated network providers must follow and the credentials they must have to contract or be affiliated with the diagnostic testing network.

(c) Any changes or amendments to the information and documentation required by subdivision (b) of this section must be filed with the chair within 20 business days after the changes or amendments are complete.

(d) Compliance with laws. An officer or managing partner of each diagnostic testing network that contracts with an insurance carrier in accordance with this Subpart shall affirm under penalty of perjury, upon submission of the documents and information required by subdivision (b) of this section, that such network is legally and properly organized under the laws of this State and this Subpart, is duly registered with the Department of State, and is in full compliance with the laws of the State of New York and the United States, including but not limited to any laws or regulations under the Public Health Law, the Education Law and the Workers' Compensation Law governing the practice of medicine, treatment of claimants, solicitation and fee splitting, and shall remain in full compliance with all applicable laws and regulations.

(e) Additional information. The chair reserves the right to request additional information and documentation from any diagnostic testing network that contracts with an insurance carrier for the purpose of administering this Subpart and the Workers' Compensation Law.

(f) Diagnostic examinations and tests shall be performed in a medical facility or professional office suitable for such examinations and tests, with due regard and respect for the privacy and dignity of the claimant. Such medical facility or professional office shall be listed with the Workers' Compensation Board and the Department of Health and/or Education as an office address for the affiliated network provider. A medical facility or professional office shall have adequate access, heat, light, space, and equipment to provide for the safety of the claimant and the integrity of the examination or test, and shall meet reasonable sanitary requirements. Medical facilities and professional offices shall meet all other requirements as established by the chair or his or her designee, and shall meet all applicable standards for accessibility as required under State or Federal law.

(g) No later than December 31, 2012, each diagnostic testing network shall only use affiliated network providers that are in compliance with the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) regarding imaging accreditation for nuclear medicine, PET, CT and MRI. In addition, each diagnostic testing network shall credential the physicians in their affiliated network providers to National Committee for Quality Assurance (NCQA) standards.

(h) Each diagnostic testing network shall have affiliated network providers open and available to perform diagnostic examinations and tests between the hours of 8:00 a.m. and 6:00 p.m., Monday through Friday, except that they need not be open and available on official holidays and religious holidays. Diagnostic examinations and tests may be scheduled outside of regular business hours only with the consent and for the convenience of the claimant.

(i) A diagnostic testing network shall have sufficient affiliated network providers in the geographic areas it serves so that diagnostic examinations and tests will be performed within five business days of the earlier of:

(1) the date that the treating medical provider ordered such diagnostic examinations and tests be performed if such diagnostic examinations and tests costs $1,000 or less or is on the list of pre-authorized procedures set forth in section 324.2(d) of this Title; or

(2) the date the insurance carrier approves the request pursuant to Workers' Compensation Law section 13-a(5) and section 324.2(d)(2) of this Title for authorization for diagnostic examinations and tests costing more than $1,000 and not on the list of pre-authorized procedures. In determining whether the cost of the requested diagnostic examination or test requires authorization by the insurance carrier, the cost of such diagnostic examination or test that is established in the applicable medical fee schedule set forth in section 329.3 of this Title shall be used to determine whether authorization for the diagnostic examination or test is required.

(j) Electromyography (EMG) and Nerve Conduction Studies (NCS).

(1) Diagnostic testing networks shall require that affiliated network providers that provide EMG and NCS studies have such studies administered and interpreted by physicians who are authorized by the chair to treat claimants and board certified in neurology or physical medicine and rehabilitation. Board certified shall have the same meaning as provided in section 300.2(b)(3) of this Title.

(2) Diagnostic testing networks shall require that affiliated network providers perform EMG and NCS studies according to standards established by the American Association of Neuromuscular and Electrodiagnostic Medicine.

(k)

(1) If the diagnostic testing network is an IPA it shall:

(i) be in compliance with all the requirements of this Subpart for a diagnostic testing network and all applicable laws and regulations including but not limited to applicable provisions of 10 NYCRR Subpart 98-1, such as sections 98-1.4(a) and 98-1.5(b)(6)(vii);

(ii) include in the certificate of incorporation or articles of organization of the IPA powers and purposes permitting the arranging by contract for the delivery or provision of diagnostic examinations and tests, by individuals, entities, and facilities licensed or certified to practice medicine and other health professions, and, as appropriate, ancillary medical services, by which arrangements such health care providers will provide their services in accordance with and for such compensation as may be established by a contract between the IPA and the insurance carrier; and

(iii) have submitted the IPA's proposed certificate of incorporation, articles of organization, or amendment thereto to the Commissioner of Health and the Education and Insurance Departments for review and received the waiver, approval, or consent of the commissioner and the Education and Insurance Departments.

(2) The IPA shall not:

(i) employ physicians or other medical providers or technicians to perform medical services or operate facilities to perform diagnostic examinations and tests; or

(ii) directly or indirectly share in the fees for professional or medical services, other than for technical or administrative services.

(l) All diagnostic testing networks and affiliated network providers shall comply and act in accordance with the Workers' Compensation Law, this Subpart, and all other applicable regulations.

N.Y. Comp. Codes R. & Regs. Tit. 12 §§ 325-7.3