Insurer Update Regarding Prior Authorization Requests Over $1,000

As you are probably already aware, the Workers’ Compensation Board (Board) recently launched Phase 3 of our new and improved business information system, OnBoard: Limited Release (OBLR), which replaces our multiple legacy, paper-based claims systems, with a single, web-based platform.

OBLR requires health care providers to submit prior authorization requests (PARs) and requests for decisions on unpaid medical bills (formerly done via the paper Form HP-1) online.

Prior Authorization Requests Over $1,000

Workers’ Compensation Law § 13-a(5) states that specialist consultations, surgical operations, physiotherapeutic or occupational therapy procedures, x-ray examinations or special diagnostic laboratory tests costing more than $1,000 can only be denied when there is a conflicting medical opinion by a Board-authorized physician. 

The Board wants insurers to be aware that a Level 1 administrative denial in a controverted case that is filed without an independent medical exam (IME) for the above-mentioned procedures, would result in a waiver of the right to obtain an IME should the case later be established.

More Information

For questions regarding this update, please email OfficeofGeneralCounsel@wcb.ny.gov.

For information regarding the OnBoard project, you can email OnBoard@wcb.ny.gov. We also urge you to visit the OnBoard section of the Board’s website for payer overview, training and resources pages and to sign up to receive news straight to your inbox.