11 CRR-NY 68.1NY-CRR
11 CRR-NY 68.1
11 CRR-NY 68.1
68.1 Adoption of certain workers' compensation schedules.
(a)
(1) The existing fee schedules prepared and established by the chair of the Workers' Compensation Board for industrial accidents are hereby adopted by the Superintendent of Financial Services with appropriate modification so as to adapt such schedules for use pursuant to the provisions of the Insurance Law section 5108.
(2)
(i) Notwithstanding paragraph (1) of this subdivision, and except as provided in subparagraph (ii) of this paragraph, the amendments to the fee schedules set forth in Parts 329, 333, 343, and 348 of Title 12 NYCRR that were promulgated by the chair of the Workers’ Compensation Board on December 11, 2018, and the amendments to the fee schedules set forth in Parts 329, 333, and 348 of Title 12 NYCRR that were adopted by the chair of the Workers’ Compensation Board on November 19, 2019, shall take effect for purposes of Insurance Law section 5108 on October 1, 2020, and shall only apply to all charges for health services performed on or after October 1, 2020.
(ii) The following ground rules in the amendments to the fee schedules set forth in Parts 329, 333, 343, and 348 of Title 12 NYCRR that were promulgated by the chair of the Workers’ Compensation Board on December 11, 2018, shall take effect for purposes of Insurance Law section 5108 on April 1, 2019, and shall apply to all charges for health services performed on or after April 1, 2019:
(a) General Ground Rule 10 in the Workers’ Compensation Chiropractic Fee Schedule set forth in Title 12 NYCRR Part 348;
(b) General Ground Rule 19 in the Workers’ Compensation Medical Fee Schedule set forth in Title 12 NYCRR Part 329;
(c) General Ground Rule 13 in the Workers’ Compensation Behavioral Health Fee Schedule (formerly the Psychology Fee Schedule) set forth in Title 12 NYCRR Part 333; and
(d) General Ground Rule 16 in the Workers’ Compensation Podiatry Fee Schedule set forth in Title 12 NYCRR Part 343.
(b)
(1) The charges for services specified in Insurance Law section 5102(a)(1) and any further health service charges that are incurred as a result of the injury and that are in excess of basic economic loss, shall not exceed the charges permissible under the schedules prepared and established by the chair of the Workers' Compensation Board for industrial accidents that are in effect for purposes of no-fault at the time the charges are incurred. However, references to workers' compensation reporting and procedural requirements in such schedules do not apply to no-fault, e.g., requirements that provide for authorization to perform surgical procedures. The general instructions and ground rules in the workers' compensation fee schedules apply, but those rules that refer to workers' compensation claim forms, pre-authorization approval, time limitations within which health services must be performed, enhanced reimbursement for providers of certain designated services, and dispute resolution guidelines do not apply, unless specified in this Part.
(2) If a fee schedule has been adopted for a licensed health provider, the fee for services provided shall be the fee adopted or established for that licensed health provider. (For example, the fee for chiropractic services performed by a chiropractor employed by a physician would be the fee applicable for chiropractic services as contained in the chiropractic fee schedule). However, if the workers' compensation fee schedule contains a specific ground rule to permit reimbursement at the physician rate then that rule will apply. (For example, the fee for services performed by a physical or occupational therapist employed by a physician would be the fee applicable at the physician rate in accordance with ground rule nine contained in the workers' compensation physical medicine fee schedule).
(3) A licensed health provider means a licensed healthcare professional acting within the scope of his or her licensure or an entity, including a pharmacy properly formed in accordance with applicable law and acting within the scope of its license.
11 CRR-NY 68.1
Current through May 31, 2021
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