Subject Numbers Regarding Health Provider Authorizations

Rescinded beginning on July 1, 2022 per SN046-1523R Medical Reporting in Rochester

January 26, 2010

Physicians, with limited exceptions, podiatrists, chiropractors and psychologists must be authorized by the Chair in order to treat workers' compensation claimants. Physical and occupational therapists may treat claimants either under the direct supervision of or upon referral by a physician. Nurses and other health providers may only treat workers' compensation claimants under the direct supervision of an authorized physician.

It is important that injured workers have access to authorized providers in order to receive necessary care and treatment. Further, it is also important that injured workers receive such care and treatment as quickly as possible in order to ensure the best and speediest recovery. The faster an injured worker is treated and recovers, the faster such worker can return to work. In order to receive treatment quickly there must be authorized providers available to treat injured workers.

In the past two years a number of physicians have voluntarily surrendered their authorizations to treat workers' compensation claimants. A large number of these physicians are located in the Rochester area of the state resulting in a temporary shortage of authorized providers to treat injured workers. Specifically, the temporary shortage of authorized physicians exists in the counties of Monroe, Livingston, Steuben, Allegany, Wyoming and Ontario.

When these providers surrendered their authorizations, injured workers treated by them were forced to find a new provider. In addition, newly-injured workers had to find other providers to treat them. This has resulted in an increased demand for the services of the providers who have retained their authorization to treat injured workers. This demand has placed a burden on authorized providers to timely complete and submit the prescribed medical report forms. Delays in the submission of medical reports cause delays in the receipt of benefits by injured workers.

I find that there is a temporary shortage of authorized providers in the counties of Monroe, Livingston, Steuben, Allegany, Wyoming and Ontario. These counties shall collectively be deemed the Provider Temporary Shortage Area.

In order to address this situation, in the Provider Temporary Shortage Area I am including in the list of prescribed medical report forms the CMS-1500 (or HCFA-1500) form with detailed narrative reports or office notes. Authorized physicians, podiatrists, chiropractors and psychologists in the Provider Shortage Area may submit a CMS-1500 with a detailed narrative report or office notes in lieu of one of the prescribed C-4 forms. If a CMS-1500 is submitted without the detailed narrative report or office notes, it is not a prescribed form. A narrative report or office notes are considered detailed when they contain the necessary information in sufficient detail so the insurance carrier can properly process the submission.

Further, the statement in Subject Number 046-301R dated March 23, 2009, that the Board will not enforce payment for examinations, services and/or treatments provided after April 1, 2009, if they are not reported using the correct new C-4 report is rescinded Statewide. In all areas of the State, the Board will enforce payment in accordance with the Workers' Compensation Law and regulation regardless of the version of the C-4 form used to report examinations, services and/or treatments rendered by providers. For providers located within the Provider Temporary Shortage Area, the Board will also enforce payment in accordance with the Workers' Compensation Law and regulations if a CMS-1500 (or HCFA-1500) with detailed narrative report or office notes is used to report examinations, services and/or treatment for the duration of the shortage.

Insurance carriers may not refuse to pay bills for failure to file one of the prescribed C-4 forms; however, they may raise an objection to the bill if the service is not sufficiently detailed in the office notes or narrative reports.

The Provider Temporary Shortage Area designation and addition to the prescribed list of medical report forms takes effect immediately. Once it is determined that the shortage no longer exists the list of prescribed medical report forms will be revised to require use of the C-4 forms.

Any questions regarding these matters should be referred to the Office of General Counsel at (518) 486-9564.