N.Y. Comp. Codes R. & Regs. Tit. 12 §§ 325-7.5

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

Section 325-7.5 - Procedures for use of diagnostic testing network

(a) Required use of diagnostic testing network.

(1) A claimant must obtain diagnostic examinations and tests through a diagnostic testing network when:

(i) the insurance carrier responsible for claimant's claim has contracted with a diagnostic testing network that is in compliance with Workers' Compensation Law section 13-a(7) and this Subpart and requires claimant to obtain or undergo diagnostic examinations and tests with an affiliated network provider; and

(ii) the insurance carrier responsible for the claimant's claim has provided the notification required in paragraph (d)(1) of this section.

(2) The requirement to obtain or undergo diagnostic examinations or tests through a diagnostic testing network applies regardless of the cost of the diagnostic examinations or tests.

(b) Use of diagnostic testing network not required.

(1) A claimant may use a facility or provider that is not affiliated with the diagnostic testing network or networks if all within a reasonable distance are unable to schedule the diagnostic examinations and tests ordered by the treating provider and as prescribed herein, or when the insurance carrier has filed or will be filing a notice of controversy with the board controverting the claim pursuant to Workers' Compensation Law section 25(2) and as described at section 325-7.4(b)(2) of this Subpart. If the claim is subsequently established by the board, then the insurance carrier will be liable for the cost of the diagnostic examinations and tests performed relating to the work-related injury at the workers' compensation fee schedule rate. However, if the claim is not established by the board, then the insurance carrier will not be liable for the cost of any diagnostic examinations and tests performed. In such event, liability reverts to the claimant pursuant to section 325-1.23 of this Part.

(2) A claimant shall not be required to obtain or undergo diagnostic examinations and tests from an affiliated network provider:

(i) prior to being provided with the notice required by paragraph (d)(1) of this section; or

(ii) in the event of a medical emergency as defined in section 325-7.1(k) of this Subpart; or

(iii) when the diagnostic testing network does not have a provider or facility within a reasonable distance from the claimant's residence or place of employment as defined in section 325-7.1(n) of this Subpart; or

(iv) the diagnostic testing network does not have a provider or facility within a reasonable distance from the claimant's residence or place of employment that can perform the diagnostic examinations and tests within five days as required by section 325-7.3(i) of this Subpart.

(c) Medical treatment guidelines. All diagnostic examinations and tests, for body parts for which a medical treatment guideline has been adopted, shall be performed in compliance with the applicable medical treatment guideline for that body part. If an affiliated network provider, or to the extent permitted by law a diagnostic testing network, requests confirmation or approval from the insurance carrier that the diagnostic examinations and tests are consistent with the medical treatment guidelines, the insurance carrier shall respond to such request promptly so that the diagnostic testing network can schedule and have the examinations and tests performed within five days as required by section 325-7.3(i) of this Subpart, unless the claimant or treating health care provider requests a specific location that can be accommodated by the diagnostic testing network.

(d) Notice.

(1) An insurance carrier that requires claimants to utilize a diagnostic testing network to obtain or undergo diagnostic examinations and tests shall include in its notice a statement that an insurance carrier's failure to comply with the notice requirements relieves the claimant of his or her obligation to use a diagnostic testing network for any necessary diagnostic examinations and tests. An insurance carrier shall:

(i) Furnish to claimants, and treating health care providers as prescribed in subparagraph (iii) of this paragraph, notice on a form prescribed by the chair that contains:

(a) the name, mailing address, telephone number, and web address for the diagnostic testing network or networks, or affiliated network providers through which the claimants must obtain or undergo diagnostic examinations and tests, as well as information regarding any other available method for scheduling an appointment such as email address or fax number;

(b) information regarding the procedures the claimants should follow to schedule diagnostic examinations and tests consistent with Workers' Compensation Law section 13-a(6) and (7) and this Subpart;

(c) a statement that the name, location address, and telephone number of at least five affiliated network providers that offer the ordered diagnostic examination and test within a reasonable distance from the injured or ill worker's residence or place of employment, or all affiliated network providers if there are less than five within a reasonable distance, will be furnished by the diagnostic testing network or networks or insurance carrier at the time diagnostic examinations and tests are ordered;

(d) a description of the types of diagnostic examinations and tests that a claimant must obtain or undergo from an affiliated network provider;

(e) a statement that directs the claimant to notify all of his or her treating medical providers that the claimant must obtain or undergo the diagnostic examinations and tests identified in the description in clause (d) of this subparagraph from an affiliated network provider identified in the notice required by this paragraph;

(f) a statement that the diagnostic examinations and tests must be scheduled and performed within five business days;

(g) a statement that the claimant is entitled to select any affiliated network provider to perform such diagnostic examinations and tests; and

(h) a statement that the claimant is entitled to determine the affiliated network provider that will perform the diagnostic examinations and tests in consultation with the treating medical provider that requested authorization;

(ii) furnish the notice required by subparagraph (i) of this paragraph to the claimant:

(a) at the same time he or she is sent the written statement of rights required by Workers' Compensation Law section 110(2); or

(b) within two weeks from the date the insurance carrier imposes the requirement to use a diagnostic testing network or networks, if the time period within which the written statement of the claimant's rights as provided in Workers' Compensation Law section 110(2) has expired;

(iii) furnish the treating medical provider with a copy of the notice required by subparagraph (i) of this paragraph:

(a) when the treating medical provider has submitted a report in accordance with Workers' Compensation Law section 13-a(4)(a), the first time that the insurance carrier either pays the treating provider's bill for treatment or notifies the treating medical provider that the insurance carrier is objecting to the bill for treatment; or

(b) by one-time mailing to all health care practices with members and all self-employed practitioners that the carrier has identified as treating medical providers who would have occasion to refer patients for diagnostic examinations or tests. A carrier selecting this method of notice must send this notice to any new health care practice or practitioner that is added to the carrier's database after the initial one-time mailing.

(2) While the insurance carrier may delegate responsibility for providing the notice required by this subdivision to the diagnostic testing network or an affiliated network provider with which it contracts, or another agent or contractor, the insurance carriers remain responsible for providing the notice and shall be liable if it is not provided in accordance with this Subpart.

(3) If the insurance carrier fails to comply with the notice requirements of paragraph (1) of this subdivision, and the claimant utilizes the services of a facility or provider that is not an affiliated network provider, the insurance carrier will be liable to pay the cost of such examination(s) and/or test(s) performed at the workers' compensation fee schedule rate.

(4) If the insurance carrier complies with the notice requirements of paragraph (1) of this subdivision, but the claimant utilizes the services of a facility or provider, including the treating medical provider, that is not an affiliated network provider for diagnostic examinations and tests, then the insurance carrier is not liable for the cost of the diagnostic examinations and tests.

(5) If an insurance carrier fails to comply with the notification requirements of this subdivision, it may be subject to sanction by the chair or his or her designee. Such sanction may include a direction that payment for the diagnostic examinations and tests, when performed by facility or medical provider that is not an affiliated network provider, be at the workers' compensation fee schedule rate, in addition to the costs incurred by the harmed party due to such failure. In cases of persistent and significant non-compliance, such sanction may include suspension or prohibition of the use of a diagnostic testing network or networks pursuant to Workers' Compensation Law section 13-a(7) and this Subpart. In addition, the chair in his or her discretion may prohibit the use of a diagnostic testing network operating in violation of any law or regulation.

(e) Reports.

(1) Reports shall be prepared for all diagnostic examinations and tests performed by affiliated network providers on behalf of insurance carriers.

(2) Affiliated network providers shall submit full and truthful reports of the impressions and medical findings of all diagnostic examinations and tests to the claimant's treating medical provider who requested the diagnostic examinations and tests. Said reports must also be filed with the board and sent to all parties of interest on the same day.

(3) Reports of all results, impressions, and/or findings of diagnostic examinations and tests shall be sent to the claimant's treating medical provider who requested such diagnostic examinations and tests and the board immediately upon completion of the report detailing the results, impressions, and/or findings but no more than three business days after such examination or test has been performed, except in the case of EMG and NCS studies which shall be sent to the claimant's treating medical provider and the board no more than seven business days after such study has been performed. The report detailing the results of such diagnostic examinations and tests may be sent electronically to the treating medical provider who requested such examination or test, as long as such provider agrees to such electronic transmission and it complies with all State and Federal privacy laws.

(f) Test film or data. When requested in writing, the actual film or test data that provides the basis for the results, impressions, and medical findings in the report of the diagnostic examinations and tests shall be delivered to the claimant's treating medical provider who requested the diagnostic examinations and tests at the same time the report is submitted or, if requested after the report has been sent, within three business days of receipt of the written request. A second diagnostic examination or test may be ordered from the diagnostic testing network due to inadequate quality and for the purpose of obtaining an accurate diagnosis as set forth in the medical treatment guidelines.

(g) Choice of facility or provider.

(1) When a claimant is required to obtain or undergo diagnostic examinations and tests from an affiliated network provider, he or she has the right to choose the facility or provider that will perform the diagnostic examinations and tests from among all affiliated network providers available in the insurance carrier's diagnostic testing network or networks. Claimant always has the right to consult with the treating medical provider who ordered the diagnostic examinations and tests when choosing the affiliated network provider.

(2) The carrier, or diagnostic testing network on its behalf, shall provide claimant with a list of affiliated network providers to choose from to perform the diagnostic examinations and tests.

(h) Relationship between claimant and provider. A limited patient-provider relationship is established as a result of conducting diagnostic examinations and tests in accordance with Workers' Compensation Law section 13-a(7) and this Subpart. The limited patient-provider relationship requires the provider to conduct objective diagnostic examinations and tests but not to monitor claimants' work related injury or illness over time, treat claimants, or fulfill the other duties traditionally held by treating providers. However, all laws and regulations governing the confidentiality of medical records and workers' compensation records shall apply to the records and reports of a diagnostic testing network and the affiliated network providers.

N.Y. Comp. Codes R. & Regs. Tit. 12 §§ 325-7.5