Overview
OnBoard is an online information system that the New York State Workers’ Compensation Board (Board) is building from the ground up. OnBoard will eventually replace the Board’s legacy paper-based claims systems, such as eCase, with a single, web-based platform, providing stakeholders with increased accuracy, paperless transactions, and a user-friendly interface for interacting with the Board. OnBoard will be a better system for a better Board.
OnBoard: Limited Release is the first phase of OnBoard, designed to move key processes for health care providers and claim administrators from paper to online. Included is the prior authorization request (PAR) process for medication, durable medical equipment and medical treatment/testing, as well the submission of Request for Decision on Unpaid Medical Bill(s) (Form HP-1.0).
Although attorneys will not be users of OnBoard: Limited Release, all documents resulting from the processing of MTG Confirmation, Durable Medical Equipment, Medication, Non-MTG Over $1,000, Non-MTG Under or = $1,000, MTG Special Services, and MTG Variance PARs, will be saved to the case folder in eCase.
What is a Prior Authorization Request (PAR)?
A PAR is a request by a claimant’s health care provider to obtain prior approval from the claim administrator (insurance carrier, self-insured employer, or third-party administrator) to cover the costs associated with a specific treatment under workers' compensation insurance. There are several categories of treatment that require prior authorization. In certain situations, PARs can be escalated for review by the Board's Medical Director's Office (MDO).
PAR Types and Time Frames for Response
| PAR Type | Request Type | Mandatory Time Frame for Insurer Response |
|---|---|---|
| MTG Confirmation | Requests previously done using the Attending Doctor's Request for Optional Prior Approval and Carrier's/Employer's Response (Form MG-1). | Eight business days |
| MTG Variance | Requests previously done using the Attending Doctor's Request for Approval of Variance and Carrier's Response (Form MG-2). |
15/30 calendar days in accordance with GCL* Insurers must respond within 15 calendar days of receipt of a request from a health care provider. If an insurer decides to request an independent medical examination (IME) or the review of records, it must notify the health care provider and Chair, through OnBoard, within five business days and respond within 30 calendar days of receipt of the request. |
| MTG Special Services | MTG-related requests previously done using the Attending Doctor's Request for Authorization and Carrier's Response (Form C-4AUTH). |
15/30 calendar days in accordance with GCL* Insurers must respond within 15 calendar days of receipt of a request from a health care provider. If an insurer decides to request an IME or the review of records, it must notify the health care provider and Chair, through OnBoard, within five business days and respond within 30 calendar days of receipt of the request |
| Non-MTG Over $1,000 | Requests for treatment(s)/test(s) costing over $1,000 with no applicable New York Medical Treatment Guidelines (MTGs) previously done using the Attending Doctor's Request for Authorization and Carrier's Response (Form C-4AUTH). | 30 calendar days in accordance with GCL* |
| Non-MTG Under or = $1,000 (new) | Requests for treatment(s)/test(s) costing $1,000 or less for non-MTG body parts. | Eight business days |
| Medication | Requests for new non-Formulary medications or refills of such medications, including medical marijuana (replacing the current New York Workers' Compensation Drug Formulary [Drug Formulary] prior authorization request process). | Four calendar days |
| Durable Medical Equipment (new) | Requests in accordance with the new Official New York Workers' Compensation Durable Medical Equipment (DME) Fee Schedule. | Four calendar days in accordance with GCL* |
*General Construction Law (GCL) 25a states: "When any period of time, computed from a certain day, within which or after which or before which an act is authorized or required to be done, ends on a Saturday, Sunday or a public holiday, such act may be done on the next succeeding business day..."
- All time frames for claim administrator review and response are automatically tracked by the system. If the claim administrator does not respond within the designated time frame, an Order of the Chair may be issued. Orders of the Chair are final, may include a penalty, and cannot be appealed.
- The time frame remains the same for notifying parties an IME is required as well as the time frame for response involving an IME.
PAR Process
Submission by Health Care Provider
Board-authorized and out-of-state health care providers must submit all PARs through OnBoard, which will guide the health care provider through a series of questions to determine which PAR type to submit. Supporting medical documentation must be entered or attached to each request.
When a PAR is submitted, OnBoard automatically forwards the request to the insurer’s claim administrator. If there is more than one, it is sent to the claim administrator who filed the most recent First or Subsequent Report of Injury (FROI/SROI) for the claim. If there are no FROI/SROI filings, then the Board will assign the PAR to an insurance carrier, self-insured employer or third-party administrator associated with the claim, who must respond. PARs cannot be reassigned among claim administrators.
PAR Review Process/Insurer Response
For all PAR types other than Medication:
- If the claim administrator’s Level 1 reviewer approves the request, the health care provider will be notified upon approval.
- If the request is granted in part or denied for medical reasons, it is automatically escalated to the claim administrator’s Level 2 reviewer (the insurer’s physician). The health care provider is notified of the decision after the Level 2 reviewer has completed their review.
- The Level 1 reviewer may deny for administrative reasons without a medical review; however, if the denial is for medical reasons or “burden of proof,” the Level 2 reviewer will be required to review the request and provide the medical rationale within the initial review time frames associated with the PAR type.
- Note: A Level 1 administrative denial in a controverted case that is filed without an IME for specialist consultations, surgical operations, physiotherapeutic or occupational therapy procedures, x-ray examinations or special diagnostic laboratory tests costing more than $1,000, would result in a waiver of the right to obtain an IME should the case later be established. These procedures can only be denied when there is a conflicting medical opinion by a Board authorized physician.
- The health care provider has the option of either treating the claimant per the decision from the claim administrator or requesting a review from the Board.
- DME, MTG Confirmation, MTG Variance and MTG Special Services PARs that have been granted in part or denied for medical reasons can be escalated by the health care provider through OnBoard for Level 3 review by the MDO and will be addressed by a Notice of Resolution issued from within OnBoard.
- Non-MTG Under Or = $1,000 PARs that have been granted in part or denied for medical reasons can be submitted by the health care provider through OnBoard for adjudication by the Board and will be addressed by a Proposed Decision from the Board.
- Non-MTG Over $1,000 PARs that have been denied for medical reasons will be addressed at a priority hearing scheduled by the Board.
- All PARs (other than Medication) that have been denied for administrative reasons and Non-MTG Over $1,000 PARs that have been granted in part can be submitted for adjudication by the Board, by the claimant or their attorney by filing a Request for Assistance/Action (RFA).
For Medication PARs:
- The health care provider is notified of the decision made by the claim administrator’s Level 1 reviewer. The reviewer can approve the request in full, grant in part or deny the PAR.
- The health care provider can agree with the claim administrator’s decision or use OnBoard to request a Level 2 review by the insurer’s physician. The request must be made within 10 days.
- If a Level 2 review is requested, the health care provider will be notified of the Level 2 reviewer’s decision.
- The health care provider can agree with the decision or use OnBoard to request a Level 3 review from the MDO.
Grant Without Prejudice:
- If the claim administrator agrees that the requested medical care is medically necessary, they may “grant without prejudice” only when either:
- The claim administrator has filed a denial (First Report of Injury [FROI-04] or Subsequent Report of Injury [SROI-04]) in the case and the controversy is still pending; or
- The body part or condition has not been accepted by the insurer or employer (with or without liability) on a FROI/SROI or established by decision of the Board. This grant without prejudice must be made by the insurer’s physician to be valid.
PAR Denial Appeals
PARs for Non-MTG Over $1,000 that are denied by the Level 2 reviewer, will be scheduled for a hearing if any requested item is fully denied for medical reasons; no request from a party is required and that hearing will be “expedited.”
Request for Further Action by Legal Counsel (Form RFA-1LC)
Claimant attorneys can submit an electronic Form RFA-1LC, which is not part of OnBoard: Limited Release, for the following:
- To request review by Adjudication after a denial by the claim administrator for administrative or no jurisdiction reasons for the following PAR types:
- Durable Medical Equipment (DME)
- MTG Confirmation
- MTG Variance
- MTG Special Services
- Non-MTG Over $1,000
- Non-MTG Under or = $1,000
- To request review by Adjudication after a partial grant or denial by the claim administrator for medical reasons that was supported by an independent medical examination for these PAR types:
- MTG Variance
- MTG Special Services
- To request review by Adjudication after a Level 3/MDO response for these PAR types:
- Medication
- DME
- MTG Variance
- MTG Special Services
Email Notifications
Claimant Attorneys
If an attorney or attorney firm has an assigned R-Number, an email address listed in their eCase profile, and is associated or on notice to the claim when a PAR is submitted by a claimant’s health care provider in OnBoard, they can receive automatic email notifications directing them to review the document in eCase whenever the following types of actions are taken on the PAR:
- Updates for PAR submission
- Responses by the insurer or claim administrator
- Orders of the Chair when there is no response from the claim administrator
- Escalation of a PAR
- Notice of resolution for a PAR
Claimant attorneys will not receive further email updates from OnBoard regarding the status of a PAR once it is under Adjudication review by the Board. The outcome of such review will be communicated by a Notice of Decision (NOD) or Notice of Proposed Decision (PD); notifications to parties regarding these decisions will be the same as other NODs or PDs issued by the Board.
Signing Up for Email Notifications
To receive email notifications, the attorney or attorney firm must have access to eCase. The attorney or firm’s eCase online administrator must provide the email address associated with the attorney or firm’s R-Number on the eCase Online Administrator’s page of the Board’s website. A single email address for a firm will be used for all PAR status change notifications for the entire firm.
- Within the eCase Online Administrator page, select Add or Update Email.
- Enter the email address associated with the attorney or firm's R-Number and select Update Email.
Once signed up, the eCase online administrator can update the email address to which notifications are sent as needed.
Insurer Attorneys
Insurer attorneys will not have the ability to submit an email address to receive PAR notifications. The insurer’s Medical Portal administrator will provide a single email to receive PAR updates for their organization.
Training & Resources
Training
- Email notifications for claimant attorneys
- PARs in eCase examples (docgens) for claimant and insurer attorneys
Videos
- Intro to OnBoard: Video
Webinars
- OnBoard: What Attorneys Need to Know – February 2022: Video / Slides
- OnBoard: Limited Release for Attorneys Webinar – June 2021: / Slides
Questions about OnBoard?
- Visit the OnBoard Support and System Requirements page.
Get Involved & Stay Informed
The Board is committed to partnering with our external stakeholders throughout the project to gain critical input to ensure the new system addresses their needs. Keep an eye on our upcoming webinars page for upcoming OnBoard webinar announcements. Your thoughts, concerns, and ideas are always welcome and appreciated. Have a question? Visit the OnBoard Support and System Requirements page.
The Board will also be sharing regular updates as we make progress on this important project. To stay informed on OnBoard, please watch this page and subscribe for email updates.