N.Y. Comp. Codes R. & Regs. Tit. 12 §§ 325-7.4

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

Section 325-7.4 - Services provided by diagnostic testing networks and affiliated network providers

(a) To the extent permitted by law, diagnostic testing networks and affiliated network providers shall be authorized to:

(1) schedule diagnostic examinations and tests of claimants with affiliated network providers;

(2) provide the notice required by section 325-7.5(d) of this Subpart; and

(3) process, pay, and raise any objections to bills for diagnostic examinations and tests.

(b)

(1) Diagnostic testing networks and affiliated network providers shall not require prior authorization or approval of any diagnostic examination and test ordered by a treating health care provider for any reason from the insurance carrier except as required by the Workers' Compensation Law and this Subchapter.

(2) In any claim controverted by the insurance carrier pursuant to Workers' Compensation Law section 25(2), where the insurance carrier will not reimburse the diagnostic testing network, or other party for diagnostic examinations and tests administered to the claimant until the controversy is resolved and the claim established, including under the provisions of Workers' Compensation Law section 21-a, the insurance carrier shall provide notice of this decision to the claimant with the notice that the right to compensation is controverted. Such notice shall be in the form prescribed by the chair, and shall state that the insurance carrier does not intend to reimburse any designated diagnostic testing network or affiliated network provider while the claim is controverted and until it is established, and the claimant may elect to use a diagnostic examination and testing facility not designated pursuant to this Part during the period that the claim is controverted. In the event the claimant prevails on his or her claim, the insurance carrier shall reimburse either:

(i) the claimant or third party that has made payment for such diagnostic examination or test; or

(ii) the diagnostic examination and testing facility that administered the diagnostic examination or test to the claimant where the diagnostic examination and testing facility has not charged the claimant or any third party for payment. Such reimbursement shall not exceed the maximum amount set by the medical fee schedule for such diagnostic examination and test. In the event the insurance carrier prevails, it shall have no obligation to reimburse the claimant, any third party that paid for diagnostic examination or test, or diagnostic examination and testing facility. Nothing in these regulations shall bar the diagnostic examination and testing facility from seeking payment or reimbursement from the claimant if the claim is not established as otherwise permitted by law.

(3) Affiliated network providers shall perform the diagnostic examinations and tests ordered by the treating medical provider exactly as they are ordered and shall not change the scope of or the diagnostic examinations and tests performed. If the affiliated network provider believes that a change in the test, examination or scope of such test or examination is required, the affiliated network provider shall consult with and obtain the permission of the treating medical provider to modify or change the scope of the ordered examination or test.

(c) Affiliated network providers, or to the extent permitted by law a diagnostic testing network, shall supply a copy of the diagnostic examination and testing report to the treating medical provider who ordered the diagnostic examination and tests and other parties of interest as specified in section 325-7.5(e) of this Subpart.

N.Y. Comp. Codes R. & Regs. Tit. 12 §§ 325-7.4