Medical Portal to Enable Electronic Submission of Variance Requests

Jeremy Janis, Esq.
Jeremy Janis, Esq.

The New York Workers’ Compensation Board announced the creation of a Medical Portal to enable electronic submission of C-4AUTH, MG-1 and MG-2 authorization requests. The portal will provide users with real time status of requests and send a notification when a status changes.   The Board claims that users will no longer need to know which form to complete when submitting a request and the portal’s user interface will ask the user questions, the answers will determine the correct path and type of treatment authorization request.

Use of the portal is not required

Health care providers may continue to submit requests using the paper forms, if they choose. It is anticipated, however, that electronic submission will make the approval process faster, reduce errors, improve data quality, and eliminate the need to submit paper authorization forms. Additionally, if a health care provider submits a treatment authorization request electronically, the payer will be required to respond to the request electronically.  If the medical provider submits a paper form, the payer must respond in kind via paper submission.

How does it work?

When the health care provider submits a treatment authorization request, the payer will receive the request in real-time if there is a WCB case number associated with the request. If there is no WCB case number associated with the request, the Board will assign one and route it to the payer. If the health care provider completes a search against the WCB Claims system and finds a match, the payer information will be returned and flood into the authorization request.

If there is no match, the health care provider will be able to complete the interview process with the information they have available to them and submit their request. The request will then be routed to the Board, rather than a payer, and the Board will locate the appropriate payer for the claim or assemble a new case if appropriate. After this action has been completed, the Board will route the request to the proper payer on behalf of the health care provider.

Health care providers will be notified of responses and reasons for denial of a treatment authorization request via a notification in their Medical Portal queue alerting them to all changes in status. Users can also log in to the Medical Portal at any time and see real-time status of the requests. All users will have the ability to see notes the payer may have made and any conflicting medical attachments the payer uploaded.

Upon submission, the Board will generate the Treatment Authorization Request and Treatment Authorization Response documents and mail them on behalf of the payer and health care provider.

Further, a copy of any document uploaded to the Medical Portal will be placed in eCase. This process occurs nightly, and the documents will be available in eCase the following morning. Registered eCase users will have access to the Medical Portal documents through both the Medical Portal and eCase.

During the submission process, health care providers can also indicate that a medical report was previously submitted and provide the date of service. This will enable health care providers to submit a request without having to attach a previously submitted medical report, preventing duplicate documents from being placed into eCase.

Medical Vendors

Further, payers who utilize medical vendors to assist with medical reviews and processing of medical treatment authorization requests will be given the ability to add authorized designees of their organization as users. This capability will give medical vendors the ability to view treatment authorization requests submitted through the Medical Portal.

Anticipated Release Date

The anticipated release was “Summer of 2016.” At the time of this writing (August 2016) the end of the summer is here and the system has not been rolled out.  Payers (insurers, third party administrators, and self-insured employers), health care providers and their staff, injured workers, and attorneys will all be able to access the system when it goes “live.”

The Board plans to have two webinars on how to use the medical portal.  The first is September 20, 2016  at 12 PM.  The second is on October 18, 2016 at 12 PM.

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Jeremy Janis is an associate attorney at Lois LLC where he defends employers and carriers in New York workers’ compensation claims. He regularly handles trials and hearings in the Hauppauge hearing point. Jeremy has extensive experience deposing medical professionals and other experts and advising on all aspects of workers’ compensation law. He can be reached directly at jjanis@lois-llc.com or 201-880-7213.