Form RFA-2 and other Board form updates
The Request for Further Action by Insurer/Employer (Form RFA-2) has been modified to better align with the process for resolving payer denials of the Workers’ Compensation Board’s New York Medical Treatment Guidelines (MTGs) Variance and MTG Special Services Prior Authorization Requests (PARs).
If the provider escalates such a denial for MDO/Level 3 review, any determination issued by the Workers' Compensation Board's (Board's) Medical Director's Office (MDO) in its Notice of Resolution is final and not subject to review for medical necessity under WCL § 23. As such, the payer may not dispute payment based on medical necessity (including whether such treatment/medication is recommended by the MTGs). This determination does not resolve any outstanding legal issues related to the claim, including but not limited to causal relationship and/or acceptance or establishment of a condition or body part.
In those instances where the claim administrator has specifically raised the issue as to whether the condition or body part is established as causally related to the claim, payment for any services provided in relation to this condition or body part are not guaranteed by this Notice of Resolution and any dispute to payment related to the issue of causal relationship raised by the payer on a Notice of Objection to a Payment of a Bill for Treatment Provided (Form C-8.1B) after the treatment is rendered may be resolved in favor of the payer.
An injured worker or injured workers’ representative may request further action on all or part of this decision by filing Request for Assistance by Injured Worker (Form RFA-1W) or Request for Further Action by Legal Counsel (Form RFA-1LC) respectively. A payer may not request further action on this decision but may continue to pursue resolution of any outstanding legal issues as necessary. For example, if the payer contends that future treatment is not related to established site or condition they should submit Form RFA-2 with the applicable request reason selected. Upon the filing of Form RFA-2 identifying unresolved outstanding legal issues pertaining to the treatment addressed by the MDO in its Notice of Resolution, the Board may refer the outstanding legal issues to Conciliation for a Proposed Decision or to hearing.
The updated version of Form RFA-2 is available as of today (12/4/2023). The prior version will continue to be accepted for 30 calendar days until 1/3/2024.
Other Board form updates
The Board periodically releases new versions of forms to obtain additional information, streamline processing and/or make forms more user-friendly. These changes make continued use of an older version of that form problematic for the Board and its stakeholders.
As such, the Board will only accept older versions of the forms listed below until January 31, 2024.
|
Form Number/Version
|
Form Title
|
|
C-32 (4/21)
|
Waiver Agreement - Section 32 WCL
|
|
C-32AF (12-21)
|
Carrier's/Self-Insured Employer's Affirmation
|
|
C-32E (7/19)
|
Section 32 - Electronic Signature
|
|
C-32-I (6/20)
|
Settlement Agreement - Section 32 WCL Indemnity Only Settlement Agreement
|
|
C-300.5 (10/16)
|
Stipulation
|
|
C-312.5 (12/10)
|
Agreed Upon Findings And Awards For Proposed Conciliation Decision (Represented Claimants Only)
|
|
DB-451 (5/19)
|
Notice of Total or Partial Rejection of Claim for Disability Benefits
|
|
OC-400.5 (6-13)
|
Attorney/Representative's Certification of Form C-3 or Notice of Controversy
|
|
OC-400.17 (8/20)
|
Attorney/Licensed Representative Request to Withdraw from Representation
|
|
OC-406 (1/18)
|
Notice of Retainer and Appearance on Behalf of Employer
|
If you submit an older version of one of these forms after January 31, 2024, Conduent will send you a letter advising that you submitted an older version until the end of February (30 days after the deadline).
Additionally, the Board only accepts the current version of the forms listed below, as previously announced:
|
Form Number/Version
|
Form Title
|
|
C-8.1B (7/22)
|
Notice of Objection to a Payment of a Bill for Treatment Provided
|
|
C-8.4 (7/22)
|
Notice to Health Care Provider and Claimant of an Insurer's Refusal to Pay All (or a portion) of a Medical Bill Due to Valuation Objection(s)
|
|
C-32.1 (1/23)
|
Section 32 Settlement Agreement: Claimant Release
|
|
DB-470 (6/22)
|
Preliminary/Final Claim for Reimbursement of Benefits Paid Under DBL
|
|
OC-400.1 (1/23)
|
Application for a Fee by Claimant’s Attorney or Licensed Representative
|
|
RFA-1LC (5/22)
|
Request for Further Action by Legal Counsel
|
|
RFA-2 (5/22)
|
Request for Further Action by Insurer/Employer
|
More information
Visit the Forms section of the Board’s website for current versions of all Board forms as well as additional information related to form updates and submission.
You can contact the Board with general questions at (877) 632-4996, and subscribe to receive Board updates straight to your inbox.
|
