Increase in Medical Authorization Request Threshold

Per the below notice posted on the New York State Workers' Compensation website, the threshold for Physical Therapy services will be increasing from $500 to $1000 effective July 11, 2007.  Currently, if a Worker's Compensation claimant (patient) is receiving physical therapy services and the physical therapy care is going to exceed $500, the provider needs to obtain prior authorization before the patient reaches the $500 threshold.  As of July 11th, the threshold increases to $1000; if a patient's physical therapy care is going to exceed $1000, the provider needs to obtain prior authorization before the patient reaches the $1000 threshold.  The July 11th effective date is based on the date that the provider is requesting prior authorization, not the patient's injury date.  So, a provider will be requesting prior authorization between today and July 10 for patients who are going to exceed the $500 threshold and a provider will be requesting prior authorization on July 11 and after for patients who are going to exceed the $1000 threshold.  The new threshold applies to the State Insurance Fund, as well as private carriers. 

Please contact Lynne Olney, NYPTA Reimbursement Coordinator, at lolney@nypta.org  if you have questions.

New York State Workers' Compensation Board
OFFICE OF THE CHAIR
20 Park Street   Albany, New York 12207

Subject:  Increase in Medical Authorization Request Threshold

To: State Insurance Fund, Workers' Compensation Insurance Carriers, Self-insured Employers, Third Party Administrators, Scheduling Services and Health Care Providers

Date: June 28, 2007

Effective July 11, 2007, the threshold amount above which prior authorization for special services, such as surgery, consultations, diagnostic testing, and physical therapy, must be requested will be increased. Section 28 of Chapter 6 of the Laws of 2007, amended Workers' Compensation Law 13-a(5) to increase the authorization threshold amount from $500 to $1,000. The increase in the threshold amount is applicable to all requests made on or after July 11, 2007. Accordingly, the five hundred dollar maximum no-request-necessary cost ceiling of Workers' Compensation Law Section 13-a(5) will increase to one thousand dollars on July 11, 2007.

If you have any questions regarding this change, please contact David Austin at the Bureau of Health Management (800)-781-2362 or david.austin@wcb.state.ny.us.

Donna Ferrara, Chair
Workers' Comp

posted 7/12/07

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