N.Y. Comp. Codes R. & Regs. Tit. 12 §§ 325-7.1

Current through Register Vol. 46, No. 50, December 11, 2024

Section 325-7.1 - Definitions

For purposes of this Subpart, the following terms shall have the following meanings:

(a) Affiliated network provider means a board authorized health care provider or a medical facility affiliated with a diagnostic testing network that performs diagnostic examinations and tests.

(b) Board means the Workers' Compensation Board, except that as provided in the Workers' Compensation Law, the decision of the board in particular cases may be by a member or panel of the board or by a Workers' Compensation Law judge.

(c) Chair means the chair of the Workers' Compensation Board.

(d) Claimant means a worker injured or ill due to a work-related accident and/or occupational disease covered by the Workers' Compensation Law and over which the board has jurisdiction.

(e) Diagnostic examinations and tests shall include for this section diagnostic tests, as defined in subdivision (g) of this section, x-ray examinations, magnetic resonance imaging, and/or other radiological examinations or tests, as defined in subdivision (m) of this section, but shall not include x-ray examinations when such x-rays are medically necessary, and an integral and routine part of the office visit for the diagnosis and treatment of fractures, possible fractures, joint dislocations, tumors, infections, loosening of surgical implants, dislocation of prosthetic joints, spinal instability, or follow-up to surgical procedures.

(f) Diagnostic testing network and diagnostic network mean an entity, including but not limited to, an independent practice association duly organized in compliance with all applicable laws and regulations, professional corporation, professional limited liability corporation, limited liability partnership, or professional partnership that contracts with insurance carriers, to arrange for the performance of diagnostic examinations and tests, pursuant to Workers' Compensation Law section 13-a(7), by contracting with affiliated network providers.

(g) Diagnostic tests means the use of physical, scientific and/or clinical methods to establish the cause and nature of a claimant's illness or injury as well as the potential subsequent functional impairment caused by the pathology, including electromyography (EMG) and nerve conduction studies (NCS). Diagnostic tests can also be used to eliminate other possible diagnoses. Diagnostic test results form the basis for claimant care. Diagnostic tests include tests customarily performed as an outpatient procedure and involve recording techniques performed by a set protocol that produces results that can later be interpreted by one or more trained licensed and authorized professionals.

(h) Independent practice association or IPA means, for purposes of this section and Workers' Compensation Law section 13-a(7), a corporation, limited liability company, or professional services limited liability company, duly organized in compliance with all applicable laws and regulations, which, as specified and permitted by its certificate of incorporation or articles of organization, contracts directly with providers of diagnostic examinations and tests, in order that it may then contract with one or more insurance carrier to make the services of such providers available to claimants.

(i) Insurance carrier means the State Insurance Fund, stock corporations, mutual corporations or reciprocal insurers with which employers are insured to provide workers' compensation coverage, employers permitted to pay compensation directly under the provisions of Workers' Compensation Law section 50(3), (3-a) or (4), and any special fund maintained by the board that is responsible for paying for medical treatment and care of injured workers, including but not limited to, the special fund for reopened cases created and governed by Workers' Compensation Law section 25-a and the Uninsured Employers' Fund created and governed by Workers' Compensation Law section 26-a. Insurance carrier shall also mean for purposes of this Subpart third party administrators responsible for all or part of the claims handling, pursuant to a contract, for the claims of the State Insurance Fund, stock corporations, mutual corporations or reciprocal insurers with which employers are insured to provide workers' compensation coverage, employers permitted to pay compensation directly under the provisions of Workers' Compensation Law section 50(3), (3-a) or (4), and any special fund maintained by the board that is responsible for paying for medical treatment and care of injured workers. Insurance carrier shall also mean for purposes of this Subpart a preferred provider organization or PPO licensed pursuant to Workers' Compensation Law section 353 as a plan that is owned, operated, or administered by an entity that provides for the delivery of all services required by the Workers' Compensation Law to all claimants covered by such plan.

(j) Legally and properly organized means an entity which is organized in accordance with all applicable State laws and regulations, and may include:

(1) a professional corporation (PC), professional limited liability company (PLLC), limited liability partnership (LLP), or professional partnership by a New York licensed physician or physicians; or

(2) an independent practice association that meets the requirements of section 325-7.3(k) of this Subpart.

(k) Medical emergency means an urgent medical condition that in the professional opinion of any reasonable medical provider requires an immediate diagnostic test, x-ray examination, magnetic resonance imaging or other radiological examination or test, in order to save the patient's life or prevent damage to a patient's long term health. For purposes of the definition of medical emergency, immediate means within 12 hours.

(l) 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 Title.

(m) Other radiological examinations or tests means examinations or tests that are customarily performed as an outpatient procedure utilizing imaging technologies to diagnose or detect a possible injury or condition, do not usually involve or require sedation or anesthesia, and involve recording techniques performed by a set protocol that produce results that can be later interpreted by one or more trained professionals. Imaging technologies used for such radiological examinations or tests may include ionizing radiation, magnetic fields, positron emission tomography, computed tomography, or ultrasound.

(n) Reasonable distance means within 25 miles of the injured or ill worker's residence or place of employment except for the following localities: within the City of New York within 5 miles of the injured or ill worker's residence or place of employment; within the Cities of Albany, Buffalo, Niagara Falls, Rochester, Schenectady, Syracuse, Troy, and Yonkers within 10 miles of the injured or ill worker's residence or place of employment; and within the Counties of Nassau, Rockland, Suffolk, and Westchester within 15 miles of the injured or ill worker's residence or place of employment. However, if there are no facilities or providers who perform diagnostic examinations and tests within such distances from the injured or ill worker's residence or place of employment, then reasonable distance means the distance between the injured or ill worker's residence or place of employment and the nearest facility or provider. In no event should travel time to the facility or provider who performs diagnostic examinations and tests exceed one hour.

N.Y. Comp. Codes R. & Regs. Tit. 12 §§ 325-7.1