N.Y. Comp. Codes R. & Regs. tit. 12 § 442.5

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

Section 442.5 - Review by the Board of a Prior Authorization Denial

(a) If the Carrier's Physician issues a denial or a partial approval, the medical provider may seek review by the Board's Medical Director's Office. The medical provider may not seek review by the Board's Medical Director's Office unless the medical provider has received a denial or partial approval by the Carrier's Physician.

(b) All requests for review of denials or partial approvals of a Prior Authorization request shall be submitted to the Medical Director's Office in the format prescribed by the Chair. The Chair or Medical Director may designate private entities to evaluate such requests for review of denials by a Carrier's Physician provided that the entity has:

1. the appropriate URAC accreditation or such accreditation/certification as designated by the Chair,

2. other demonstrated expertise and criteria established by the Board; and

3. no conflict of interest exists in resolving the subject dispute.

(c) When a prescribing medical provider wishes to request review of a denial or partial approval of a Prior Authorization request, the medical provider shall submit the request to the Medical Director's Office in the format prescribed by the Chair within 10 calendar days of the denial date together with all documentation submitted in support of its Prior Authorization request, and the denial or partial approval issued by the Carrier's Physician.

(d) A decision by the Medical Director's Office (or designated accredited entity) is final and binding on the medical provider, the carrier, self-insured employer or third-party administrator. Such decision shall be binding and not appealable under Workers' Compensation Law section 23.

(e) Notwithstanding paragraph (d) herein, a claimant may request review of a Medical Director's Office decision, by filing a Request for Further Action, that demonstrates that such durable medical equipment is medically necessary and denial of the Prior Authorization request adversely impacts the claimant's interests. The Board may respond to such requests for review by letter or by referral to adjudication, as appropriate in the discretion of the Chair or his or her designee. Such decisions shall be binding and not appealable under Workers' Compensation Law section 23.

(f) In the event that a Prior Authorization request is denied on the merits, the medical provider may not submit a request for Prior Authorization for the same durable medical equipment unless he or she submits evidence that there has been a change in the claimant's medical condition that renders the denial of the request for Prior Authorization no longer applicable to the claimant's current medical condition.

N.Y. Comp. Codes R. & Regs. Tit. 12 § 442.5

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