OnBoard

Overview

OnBoard is an application that is accessed from the Medical Portal. OnBoard: Limited Release is the first phase of OnBoard, designed to move key processes for health care providers and payers from paper to online. Included is the prior authorization request (PAR) process for treatment that falls outside of the Workers' Compensation Board's New York Medical Treatment Guidelines (MTGs) and other variances, as well the submission of Request for Decision on Unpaid Medical Bill(s) (Form HP-1.0)

What is a Prior Authorization Request (PAR)?

A PAR is a request by an injured worker's health care provider to obtain prior approval from the payer (e.g., insurance carrier) 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

• Medication - request for non-formulary medication(s), including medical marijuana.
• MTG Confirmation - confirmation that the proposed treatment(s)/test(s) are based on a correct application of the Medical Treatment Guidelines; replaces Attending Doctor's Request for Optional Prior Approval and Carrier's/Employer's Response (Form MG-1). Submission of MTG Confirmation is optional for health care providers, but response is mandatory for payers.
• MTG Variance - request for treatments/tests that vary from the Medical Treatment Guidelines; replaces Attending Doctor's Request for Approval of Variance and Carrier's Response (Form MG-2).
• Non-MTG Over $1,000 - request for treatments/tests costing more than $1,000 with no applicable Medical Treatment Guideline; replaces Attending Doctor's Request for Authorization and Carrier's Response (Form C-4Auth)
• Non-MTG Under or = $1,000 - requests for treatment/test costing $1,000 or less with no applicable Medical Treatment Guideline.
• MTG Special Services - request special services as required per the Medical Treatment Guidelines; previously submitted on Form C-4Auth.
• Durable Medical Equipment (DME) - request DME not on the Official New York Workers' Compensation Durable Medical Equipment (DME) Fee Schedule or for an item on the fee schedule that requires prior authorization.

Board-authorized and out-of-state health care providers must submit all PARs through OnBoard which will automatically route the request to the appropriate payer for review. Paper forms can no longer be faxed, emailed, or mailed. The type of PAR a health care provider can submit varies by profession and is outlined in the table below:

	Medication	Confirmation	Variance	Non-MTG Over $1000	Non-MTG Under or = $1000	Special Services	DME
Acupuncturist				x	x
Chiropractor		x	x	x	x		x
Licensed Clinical Social Worker		x	x	x	x
Physician	x	x	x	x	x	x	x
Physician Assistant	x	x	x	x	x		x
Nurse Practitioner	x	x	x	x	x	x	x
Podiatrist	x	x	x	x	x	x	x
Psychologists		x	x	x	x
Physical Therapists				x	x
Occupational Therapist				x	x
Dentist	x			x	x		x
Audiologists				x	x		x
Optometrist				x	x		x

Access & Administration

Payers will need to log into the Medical Portal to access OnBoard. Every user will need their own login credentials; a single login cannot be provided to an organization to be used by all users who are part of that organization. There is no limit to the number of users an organization can have.

• 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 - Pharmacy benefit managers (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.

Roles

There are multiple roles designated within OnBoard:

• Online (User) Administrator
  • 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.
  • Online administrator's for payers must also provide the email address for their PBM or other party responsible for informing the pharmacy of the approval or denial of a Medication PAR, allowing for all medication-related decisions to be automatically sent to the appropriate party.

If a payer works with multiple PBMs, it is suggested that the contact email address be a shared mailbox within the payer's organization and managed by someone who can distribute the information to the correct PBM.

• Workload Administrator
  • Receives and assign all submitted PARs based on the assigned workload administrator role.
• Level 1 Reviewer
  • Can be anyone designated by the insurer.
• Level 2 Reviewer
  • Must be the payer's physician (as per 12 NYCCR Part 441.1(g)).

Learn more about how to access the Medical Portal, online administration and how to assign roles for OnBoard by visiting Medical Portal New User Access and Administration for Payers.

eForms

Forms within OnBoard are called eForms. These interactive, browser-based screens pre-populate with any known data and guide the user to fill in any remaining required information.

eForms:

• Validate information to flag inaccuracies or incomplete items before submission
• Allow attachment of necessary documentation, such as medical records or progress notes
• Can be saved as a draft and completed at another time
• Generated documents are placed in the electronic case file immediately
• Can be downloaded as a PDF once submitted - see how to view, print or download documents in OnBoard or see sample PDFs.

How the Payer is Determined

The health care provider must search for a matching claim prior to starting a PAR. After two unsuccessful attempts to locate the claim, the health care provider will be able to continue with the request by manually entering any known information. When the health care provider submits the PAR, OnBoard will automatically forward the request to the appropriate payer for review based on the insurer's eClaims sender number that is on file for that claim. If there is no sender number found, the PAR will be subject to a manual review by the Board and will be forwarded once the correct payer is determined.

Email Notifications

PAR notifications are sent to the email address the payer's online administrator has registered for that PAR type/level. Payers are encouraged to use group emails when possible rather than an individual user's email. For example, ABC Insurance Company may register level1rx@abcinsurance.com for Level 1 medication PAR notifications and ABC Insurance Company can provide access to that email for their various administrators/users.

The system generated emails come from the same email address, regardless of PAR type - allowing users to filter and organize notifications in their inbox.

OnBoard Dashboard

When a user logs into OnBoard, they will see all active requests in need of a response on a dashboard that will contain high-level information about each PAR. Dashboards will vary based on a user's role in the system. However, they all have similar functionality such as sorting and allowing the user to visually identify which PARs need review.

A PAR submission will initially appear on the Workload Administrator's dashboard. The Workload Administrator will assign the request to individual reviewers.

Individual reviewers will also have a dashboard to respond to their assigned requests.

More detailed information can be found on the Payers Training - Dashboard page

PAR Process

Submission by Health Care Provider

The OnBoard system will guide the health care provider through a series of questions to determine which PAR type to submit. Treatments, services, and equipment requests can be added as separate line items on a single submission. The system will then convert these into one or more PARs depending on what is being requested. Line items within the same PAR family will be combined into a single PAR. If there are multiple medication items being requested, each will get their own individual PAR.

Time Frames for Payer Response

• All time frames for payer review and response are automatically tracked by the system. If the payer does not respond within the designated time frame, an Order of the Chair may be issued.
• The time frame for notifying parties an IME is required as well as the time frame for response involving an IME remains the same.
• The payer's response to a Confirmation PAR, (previously done using Form MG-1), is mandatory within eight business days.
• Payers can request additional information from the health care provider who submitted the PAR directly from within OnBoard. This feature does not affect the mandatory time frame for response to a PAR and a health care provider is not obligated to respond. However, the provision of the requested information will enable the reviewer to more completely review the submitted PAR.

See the table below for mandatory time frames for payer response for all PARs.

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 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 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	Non-Formulary medication requests, including medical marijuana.	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..."

Workload Administrator

The payer's workload administrator:

• sees all PAR requests in their dashboard,
• assigns all PARs to reviewers
• can change assigned reviewers due to situations such as a reviewer being absent from work

PAR Reviews

For all PAR types other than Medication:

• If the payer's Level 1 reviewer approves the request, the health care provider will be notified upon approval.
• Health care providers are not required to submit a PAR if they believe the requested treatment is based on a correct application of the MTGs, but if they choose to submit a Confirmation PAR (formerly Form MG-1), the payer is required to respond.
  • The system will not automatically confirm if treatment is consistent with the MTGs. The payer needs to review the request and respond if it is consistent with the guidelines, based on the specifics of the claimant's case.
  • The MTG Lookup Tool can be used to search MTGs and check that the treatment is recommended. Payers interested in using the MTG Lookup Tool can learn more by viewing the MTG Lookup Tool training video, which includes details regarding how payers can gain access
• If the request is granted in part or denied for medical reasons, it is automatically escalated to the payer's Level 2 reviewer (the payer'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. An IME can be used to inform the Level 2 decision (made by the payer's physician) but does not replace the Level 2 review.
  • 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.
• Where a treatment has been requested multiple times over the life of a claim, reviewers will be able to view those prior determinations within OnBoard, if they were submitted and responded to from within the OnBoard system. Requests submitted prior to OnBoard can be found in eCase.
• The health care provider has the option of either treating the injured worker per the decision from the Level 2 review or requesting a Level 3 review by WCB. Note that any denial of a Non-MTG Over $1,000 PAR will be addressed at a priority hearing scheduled by WCB and that no administrative denials are eligible for Level 3 review (except for Medication PARs); if the patient disagrees with the denial they must request WCB adjudication review by submitting a Request For Assistance (RFA).

For Medication PARs:

• The health care provider is notified of the decision made by the payer'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 payer's decision or submit a request using OnBoard for a Level 2 review by the payer's physician.
• 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 payer's decision or use OnBoard to request a Level 3 review from the MDO.

A full visual walkthrough using the Drug Formulary as an example is available as part of the recorded OnBoard: Limited Release for Health Care Providers webinar.

Grant Without Prejudice:

• If the payer agrees that the requested medical care is medically necessary, they may "grant without prejudice" only when either:
  • The payer 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 can only be made by the insurer's physician at the Level 2 review to be valid.

MDO Reviews:

The determination by the Board's MDO for medical necessity of MTG related procedures, DME or medication requests are final. The payer may not dispute payment based on medical necessity (including whether such treatment, DME or medication is recommended by the MTGs). A determination by the Board's MDO regarding medical necessity is not a guarantee of payment and does not resolve any outstanding legal questions, such as whether the injury was work related. The payer may still object to payment regarding a legal question. All legal issues must be raised as part of the initial Level 1 or Level 2 review.

PAR Denial Appeals:

• If the injured worker or their legal representative does not agree with the MDO's resolution, they may request an additional review via adjudication by using a Request for Assistance by Injured Worker (Form RFA-1W) or Request for Further Action by Legal Counsel (Form RFA-1LC).

Durable Medical Equipment (DME)

DME PARs must come from the treating health care provider for any item with the designation of "PAR", or any item not found on the Official New York Workers' Compensation Durable Medical Equipment (DME) Fee Schedule.

Payers may not direct a claimant to use a specific supplier of durable medical equipment, medical/surgical supplies, and orthotic and prosthetic appliances, except as part of a certified preferred provider organization. Self-insured employers and insurance carriers, including their agents and designees, may recommend a supplier of durable medical equipment, medical/surgical supplies, and orthotic prosthetic appliances.

If the payer has a dedicated DME network, they have the option to indicate that as part of their review process. It is the responsibility of the payer to make sure that they indicate the contact information of the DME supplier and that it is within a pre-prescribed distance to the claimant. Please reference the DME regulations for more detailed information.

The payer may not require the claimant to use a specific DME supplier just because they are contracted. They may, however, approve an identical line item at a lower cost, but will be required to provide two vendors (including contact information) where the injured worker may obtain the comparable item at the specified cost.

Independent Medical Examinations (IMEs)

Notification that an IME is required is only necessary for MTG Variance and MTG Special Services PARs. This notification can be made by the Level 1 or Level 2 reviewer and the time frame for response will be calculated based on the date the PAR was submitted regardless of whether the IME request was made during a Level 1 or Level 2 review.

PAR Status Updates

The system will automatically update the health care provider's and payer's dashboard and send an email or text message when a PAR status changes.

For Medication PARs, a notification will be sent to the email address identified by the payer for the PBM, or other party responsible for informing the pharmacy, of the approval or denial for the release of the requested medication.

Notification to Claimant

• Health care providers are required to notify the claimant when they submit or escalate a PAR.
• Payers are required to provide the claimant a copy of their response to a PAR.
• When the Board takes action on a PAR the claimant will be sent a copy of the Order of the Chair or MDO Notice of Resolution.

If the claimant is represented, their attorney will be notified of any action that has been taken if the attorney:

1. is identified as a claimant attorney on the claim in eCase and
2. has an email address associated with the "R" number at the time the PAR was submitted.

These rules apply to all PAR types except Medication PARs. Upon notification of an action, the attorney will retrieve the associated documentation from eCase.

Training & Resources

Training

• Training for Payers

Videos

• Intro to OnBoard: Video

Guides

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

Webinars

• OnBoard: Limited Release Q&A Webinar for Payers - June 2022: Video / Slides
• OnBoard: Limited Release Phase Three / Treatment/Testing PARs Q&A Webinar for Payers - May 2022: Video / Slides
• OnBoard: Limited Release Training for Payers - Phase Three / Treatment/Testing PARs - April 2022: Video / Slides
• OnBoard: Limited Release Phase Two / Durable Medical Equipment PARs Q&A Webinar for Payers - April 2022: Video / Slides
• OnBoard: Limited Release Training for Payers – Phase Two / DME PARs – March 2022: Video / Slides
• OnBoard: Limited Release Phase One / Medication PARs Q&A webinar for Payers – March 2022: Video / Slides
• OnBoard: Limited Release Training for Payers – Phase One / Medication PARs – February 2022: Video / Slides
• OnBoard: Limited Release for Insurers Webinar – April 2021: Video / Slides

Questions about OnBoard?

• Visit the OnBoard Support and System Requirements page..

Technical Assistance

• Contact WCB Online Services Technical Support

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.

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