The regulations require insurers:

• Incorporate the Medical Treatment Guidelines into their policies, procedures, and practices and report their compliance to the Workers' Compensation Board.
• Payer's Medical Portal Online Administrator must designate contacts for PAR review.
• Payer's Medical Portal Online Administrator must notify the Board when designated contact information changes.
• Pay providers for services rendered in accordance with the Guidelines.

Medical Portal

Payers and their designated pharmacy benefits managers (PBM) and medical review organizations (MRO) will use the Medical Portal to access the MTG Lookup Tool, Drug Formulary Lookup Tool, and OnBoard.

OnBoard

When a health care provider submits a prior authorization request (PAR), OnBoard will automatically forward the request to the appropriate claim administrator for review. When a payer logs into OnBoard, their dashboard "home screen" will display all active requests in need of a response. Payers can also receive email updates notifying them that there is a PAR in the system that needs their response.

What PARs Will Be Included?

MTG Confirmation	Requests (previously done using the Attending Doctor's Request for Optional Prior Approval and Carrier's/Employer's response (Form MG-1)).
MTG Variance	Requests (previously done using the Attending Doctor's Request for Approval of Variance and Carrier's response (Form MG-2)).
MTG Special Services	Requests, which only include the 12-MTG related requests on the Attending Doctor's Request for Authorization Carrier's Response (Form C-4 AUTH).
Non-MTG Over $1000	Requests for treatment costing over $1000 for Non-MTG body parts previously done on Form C-4 AUTH.
Non-MTG Under or = $1000	Requests for treatment costing $1000 or less for Non-MTG body parts (new PAR type).
Medication	Requests (replacing the current New York Workers’ Compensation Drug Formulary (Drug Formulary) prior authorization request process).
Durable Medical Equipment	Requests in accordance with the new Official New York Workers’ Compensation Durable Medical Equipment (DME) Fee Schedule (new PAR type).

There are different levels of review for all PARs utilizing automatic routing and escalation processes. The payer, PBM and MRO will be responsible for designating and maintaining Workload Administrators and Level 1 and Level 2 review contact information, as appropriate.

All submitted requests will be visible via a dashboard that will contain high-level information about each PAR and can be used by the Workload Administrator to assign the request to individual reviewers. Individual reviewers will also use a dashboard to respond to their assigned requests.

For all PAR types other than Medication: If the Level 1 Reviewer for the payer does not approve the request in full, then it is automatically escalated to the Level 2 Reviewer.

Access to the Medical Portal and OnBoard

• Payers – The claim administrator (insurer, self-insured entities, or third–party administrator) access is granted using organizational profiles based on eClaims Trading Partner information. The payer is ultimately responsible for the review of PARs.
• Medical Review Organization (MRO) – A payer may designate a medical review organization to review their PARS, however the medical review organization must first complete the online Medical Review Organization Medical Portal registration process.
• Pharmacy Benefit Manager (PBM) – PBMs may be designated by the payer to review Level 1 Medication PARs. The PBM must complete the online PBM Medical Portal registration process prior to a payer designating them as the reviewer. PBMs who had access to the Drug Formulary application were automatically given access to OnBoard and existing designations by payers will automatically continue.

Online Registration Process

Payers who had access to the Drug Formulary application were automatically given access to OnBoard. However, online administrators should ensure that Workload Administrators and Reviewers are designated for all PAR types and the email address for notifications is correct. All others will need to follow the below registration process.

MROs and PBMs must first complete an online registration to access OnBoard.

All information must be complete and accurate.

• Organization Information
  • Federal Tax Identification Number (FEIN)
  • Organization name
  • Organization address
• User Information – As part of the registration process, organizations must identify at least one User Administrator and may also designate additional User Administrators, Workload Administrator(s) and Reviewers. Learn more about user roles in OnBoard.
  • Information required for each user includes:
    • Name
    • Address
    • Phone number
    • Email address

Confirmation of Submission to the Board

Upon submission of your registration, a confirmation that it was successfully submitted to the Board will appear in your web browser.

After Application Has Been Submitted

It typically takes three to five business days for the Board to complete the review of a registration. Upon approval, emails will be sent to each user designated in the application with their NY.gov ID, temporary password, and additional instructions related to their role.

Roles

There are multiple roles designated within OnBoard:

Payer Roles

Role	Responsibility
Payer Online (User) Administrator	Request access for users and user administrators Assign users to Workload Administrator, Level 1 and Level 2 Reviewer roles Provide email contacts for PAR Notifications Designate MRO for PAR reviews Designate PBM for Level 1 Medication PAR reviews Update user information as necessary Remove users who should no longer have access to the system
Workload Administrator	The Workload Administrator will receive and assign all submitted PARs based on the assigned workload administrator role. Types of Workload Administrator roles: MTG/Non-MTG – assigns MTG Confirmation, MTG Variance, MTG Special Services, Non-MTG Over $1000 and Non-MTG Under or = $1000 PARs to appropriate reviewers. Medication – assigns Medication PARs to appropriate reviewers DME – assigns DME PARs to appropriate reviewers Workload Administrators may have more than one role. Payers should ensure that there is a workload administrator for all PAR types. Change delegated reviewers due to situations such as a delegate being absent from work or a change in a delegate’s role within the organization.
Level 1 Reviewer	Performed by the payer; can also be delegated to an MRO, or to a PBM for Medication PARs. Review Level 1 requests (as designated and assigned) There is a Level 1 Reviewer role for each PAR type
Level 2 Reviewer	Performed by the carrier’s physician; can also be delegated to an MRO. Please see Subchapter M of Chapter V of Title 12 of NYCCR Part 441.1(g) for the definition of the Carrier’s Physician. Review Level 2 requests (as designated and assigned) There is a Level 2 reviewer role for EACH PAR type

Medical Review Organization Roles

Role	Responsibility
Online (User) Administrator	Request access for users and user administrators Assign users to Workload Administrator, Level 1 and Level 2 Reviewer roles Update user information as necessary Remove users who should no longer have access to the system
Workload Administrator	The workload administrator will receive and assign all submitted PARs. Change delegated reviewers due to situations such as a delegate being absent from work or a change in a delegate’s role within the organization.
Level 1 Reviewer	Review Level 1 requests (as designated and assigned)
Level 2 Reviewer	Review Level 2 requests (as designated and assigned)

Pharmacy Benefit Manager Roles

Role	Responsibility
Online (User) Administrator	Request access for users and user administrators Assign users to Workload Administrator and Level 1 Reviewer roles for Medication PARs Update user information as necessary Remove users who should no longer have access to the system
Workload Administrator	The workload administrator will receive and assign all Medication PARs. Change delegated reviewers due to situations such as a delegate being absent from work or a change in a delegate’s role within the organization.
Level 1 Reviewer	Review Level 1 Medication PARs (as designated and assigned)

Online Administration

The Online Administrators for payers, MROs and PBMs are responsible for creating and maintaining the required contacts and appropriate users needed to review and respond to PARs. The Online Administrators are required to maintain accurate information within the application. PARs will be routed using the contacts and users identified by the administrator.

General Online Administration

Maintaining Online Administrators

Select the Online Administrators from the menu. The first table on the page will display a list of online administrators that have been designated by the organization. There must be at least one Online Administrator, however the Board recommends having more than one.

Online Administrators will add/modify/remove users who can assign or review PARS well as adding or removing other administrators for the organization. They are required to maintain accurate information within the application.

Assigning Workload Administrators

Select the Workload Administrator type from the menu. The first table on the page will display a list of Workload Administrators that have been designated by the organization. There must be at least one Workload Administrator.

The second table will display a list of users assigned to the organization who are not Workload Administrators for that PAR type. You may select a user from this list and choose the add button to make the user a workload administrator.

If the user is not in the list, use the Add User function.

PAR Type - Level 1 Reviewer

Select the Level 1 Reviewer PAR type from the menu. The first table on the page will display a list of Level 1 Reviewers that have been designated by the organization for that PAR type.

The second table will display a list of users assigned to the organization who are not Level 1 Reviewers for that PAR type. You may select a user from this list and choose the add button to make the user a Level 1 Reviewer.

If the user is not in the list, use the Add User function.

NOTE: If a payer designates an MRO, or a PBM for Level 1 Medication PAR review, the MRO or PBM online administrator will maintain users within their organization profile that may review requests.

PAR Type - Level 2 Reviewer (Payer and MRO)

The individual(s) responsible for reviewing Level 2 PARs for a specific PAR type must be the insurer’s physician or a designated MRO. If a payer designates an MRO, the MRO User Administrator will maintain users within their organization profile that may review requests.

Select the Level 2 Reviewer PAR type from the menu. The first table on the page will display a list of Level 2 Reviewers that have been designated by the organization for that PAR type.

The second table will display a list of users assigned to the organization who are not Level 2 Reviewers for that PAR type. You may select a user from this list and choose the add button to make the user a Level 2 Reviewer.

If the user is not in the list, use the Add User function.

Maintenance of User Information

Add, modify or remove user information for the user types as follows:

Adding a User

• Select the Add User button from the User screen for the role you want the new user to have.
• Enter the requested user’s information and submit.
• A pop-up message with a confirmation of the submission will appear.
• User requests are processed in the order that they are received. Access may be granted as early as the following business day or may take three to five businesses for processing.
• The user’s login credentials will be emailed to the email address entered in the request.

Modifying a User

You can update a user’s information, by selecting the Modify button in the row containing that user.

Removing a user

Select the user from the first table on the screen for the role they are being removed from and choose the Remove button. It will take approximately 20 minutes for the system to remove the role. NOTE: An online administrator cannot remove themselves from this role.

Responsibilities Specific to Payers

The Payer Online Administrator is an employee of the insurer, self-insured employer, or Third-party Administrator (TPA). The Payer Online Administrator will use the online Medical Portal Administration application to keep designated contact and user information up to date.

NOTE: All Online User Administrators for the Drug Formulary system were automatically granted access to OnBoard and will use the same login credentials. This allows administrators to add users to the additional roles that are required for their organization, as well as add new notification emails.

• Maintenance of Notification Contact Information: Email addresses should be kept current as it will be utilized for routing PARs. The email address for Level 1 reviews may be the same for all associated entities or entered separately. The email address for Level 2 may also be the same for all associated entities or entered separately. Note: Level 1 and Level 2 email addresses cannot be the same.
  • Level 1 - Enter/update information in the following fields:
    • Current Email - Displays current email address for the Level 1 contact.
    • Email Should Be - Enter to update the Level 1 email address.
    • Name of PBM/MRO - Select the desired Pharmacy Benefit Manager (PBM) or Medical Review Organization (MRO). The PBM registration or MRO registration must have been completed before they can be selected by the payer within the application.
  • Level 2 - Enter/update information in the following fields:
    • Current Email - Displays current email address for the Carrier’s Physician.
    • Email Should Be - Enter to update the Level 2 email address for the Carrier’s Physician.
  • Order of the Chair - Both the claim administrator AND insurance carrier must have emails listed. A notification that an Order of the Chair has been generated, will be sent to both entities.
  • Final Determinations - Email address for PBM or other party responsible to receive all medication-related decisions and inform the pharmacy of the approval or denial of a Medication PAR. The Board strongly recommends this be a shared email address.

Administrator Login

Resources

Guides

• OnBoard: Registration Guide - Payers, Pharmacy Benefit Managers and Medical Review Organizations: Guide / Video

Contact

NYS Workers' Compensation Board
Riverview Center
150 Broadway
Attn: WCB Medical Director's Office
Suite 195
Menands, NY 12204
(800) 781-2362

MDO@wcb.ny.gov