N.Y. Comp. Codes R. & Regs. Tit. 12 § 324.1 - Definitions
For purposes of this Subchapter:
(a) The definitions of the terms in section
300.1(a) of this
Title are applicable to this Subchapter.
(b)
Calendar day means the time
period from midnight to midnight. For the purposes of calculating calendar
days, the day of submission is day zero and the first calendar day begins at
midnight following the submission.
(c)
Carrier's Physician means a
physician or physicians, licensed by New York State, or the appropriate state
where the professional practices, who is:
1.
employed or contracted by the insurance carrier, self-insured employer, or
third-party administrator; or
2.
employed by a URAC accredited company retained by the insurance carrier,
self-insured employer, or third-party administrator through a contract to
review prior authorization requests and advise the insurance carrier,
self-insured employer, or third-party administrator; and
3. is not employed or contracted by the
carrier, self-insured employer, or third-party administrator's recommendation
of care network.
(d)
Consistent with the Medical Treatment Guidelines means within the
criteria of the Medical Treatment Guidelines and based on a correct application
of the Medical Treatment Guidelines.
(e)
Denial, deny or
denies means a denial or a partial approval by an insurance
carrier, self-insured employer, or third-party administrator of a Prior
Approval Request, defined herein, made pursuant to section
324.3 of this Part or a prior
approval request made pursuant to section
324.4 of this Part.
(f)
Maximum Medical Improvement
(MMI) means a medical judgment that
(1) a claimant has recovered from the work
injury to the greatest extent that is expected and
(2) no further improvement in his or her
condition is reasonably expected. The need for palliative or symptomatic
treatment does not preclude a finding of MMI. In cases that do not involve
surgery or fractures, MMI cannot be determined prior to six months from the
date of injury or disablement, unless otherwise agreed to by the parties.
A finding of maximum medical improvement is a normal precondition for determining the permanent disability level of a claimant.
(g)
Medical Director's Office means the Medical Director of the Board,
the Executive Medical Policy Director, the Assistant Medical Director of the
Board, or their designee.
(h)
Medical care means all care, treatment, and other attendance for
an injured worker's injury, illness or occupational disease as listed and
provided in Workers' Compensation Law Sections 13, 13-b, 13-k, 13-l, and
13-m.
(i)
Medical Treatment
Guidelines means the treatment guidelines for workers' compensation
injuries, illnesses, or occupational diseases to the parts of the body
addressed in the guidelines incorporated by reference in section
324.2(a) of this
Part.
(j)
Prior
Authorization means the carrier, self-insured employer, or third-party
administrator's approval of a Prior Authorization request initiated by the
medical provider.
(k)
Carrier's physician's medical report means the evaluation of a
claimant without physical examination, by the Carrier's physician, based on the
review of reports and records, including treatment notes, diagnostic test
results, depositions or hearing testimony, exhibits, and other records or
reports from medical providers or independent medical examiners or both in the
electronic case file maintained by the Board.
(l)
Prior Authorization Request
(PAR) shall mean any of the following: a variance request (PAR: MTG Variance)
or a request for special services (PAR: Special Services) made pursuant to
section 324.3 herein, or a request
confirming consistency with Medical Treatment Guidelines (PAR: MTG
Confirmation) or confirming medical necessity when there is no Medical
Treatment Guideline that addresses treatment for the body part or condition and
the treatment costs less than $1000 ( PAR: Non-MTG $1,000 or Under) as defined
in 324.4. "Prior Authorization Request" or "PAR" may also mean a prior
authorization request for medical care costing more than $1000 when there is no
Medical Treatment Guideline that addresses treatment for the body part or
condition (PAR: Non-MTG Over $1,000) made pursuant to section
325-1.4 of this Chapter.
(m)
Treating medical provider
means a duly licensed acupuncturist, chiropractor, nurse practitioner,
occupational therapist, physical therapist, physician, physician assistant,
podiatrist, psychologist, or social worker authorized by the chair, as such
terms are defined in section
13-b
of the workers' compensation law, or any provider not permitted to obtain
authorization in New York State and who has not surrendered or had a Board
authorization suspended or revoked, and (1) is licensed pursuant to the
education law to provide medical care and treatment in the state of New York,
or (2) is duly licensed pursuant to the laws of another state to provide
medical care and treatment, who is providing treatment and care to an injured
worker pursuant to the Workers' Compensation Law.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.