New York Adopts Workers’ Comp DMEPOS Fee Schedule and Authorization Rules

The New York Workers’ Compensation Board (WCB) has released final adopted rules on the Durable Medical Equipment Prosthetics Orthotics and Supplies (DMEPOS) fee schedule and synergistic prior authorization requests (PAR) requirements.

Issued on March 4, 2021, the newly adopted rules and fee schedule (FS) will transfer the existing DMEPOS FS from the current state Medicaid rates to new state-specific workers’ compensation rates, which are created and maintained by the WCB.

Additionally, the newly-adopted rules implement prior authorization requests (PAR) requirements for DMEPOS, which will utilize the electronic web-based OnBoard system for handling and responding to all submitted PARs. The new FS and all PAR requirements will take effect June 7, 2021.

New DMEPOS fee schedule
The newly-adopted FS will move reimbursement for DMEPOS provided as part of a workers’ compensation claim from the Medicaid-assigned rate to the state-specific DMEPOS rate.

Additionally, the new fee schedule provides:

• A maximum reimbursement rate for the item and item description
• A rental rate (if the item is rented compared to purchase)
• An associated HCPCS code
• A PAR indicator ― subject the item to PAR utilizing the OnBoard system 

For items not listed on the FS, besides requiring PAR, the provider and payer should come to an acceptable reimbursement rate as part of the PAR process.  With adoption of the final rule, the FS rates will now apply to all DMEPOS items provided on or after June 7, 2021. 

Prior authorization requirements
Included in the published FS is a PAR indicator that signals mandated authorization is required for the DMEPOS item before it can be supplied or provided to the claimant. While the PAR requirements are similar to those in place for the current drug formulary, there are significant differences.

• When a DMEPOS item is indicated on the FS as PAR or when the item is not on the FS, the provider – defined as physician, nurse practitioner, physician assistant, podiatrist, chiropractor, dentist, optometrist and audiologist – shall request PAR utilizing the electronic web-based OnBoard system.
• If the item is not listed on the FS, the provider and the payer, via PAR, should come to an agreement of the medical necessity of the item and a reimbursement rate.
• A PAR requesting DMEPOS rental – exceeding one week – shall also agree on the length of need for a rental item as well as a reimbursement rate.
  

A payer shall provide the WCB with the name and point-of-contact information (including an email address) for the contacts – an internal group or external vendor – for PAR request reviews. 

Prior authorization process
To initiate a PAR, a medical provider shall submit the PAR to the payer or their designated contact utilizing the manner prescribed by the WCB (OnBoard).  Once received, the payer has four calendar days to provide a response to the provider of approved, partially approved or denied. The payer (or their entity) shall also send a notice of the determination to the claimant.  When issuing a partial approval or denial of the item, payers have certain responsibilities to communicate the provider’s determination. 

If the response is a partial approval, the payer can:

• Return the response by authorizing the DMEPOS with a different HCPCS code than was requested
• Modify the rental request for either a different time frame or reimbursement rate
• Authorize the DMEPOS not listed in the FS at a different reimbursement rate than what was requested in the PAR

When a payer partially approves or denies a PAR request, the:

• Payer’s physician will issue the partial approval or denial
• Payer will provide inform the provider how to request review of the denial from the WCB.

If a provider wishes to appeal the PAR determination, they must submit the request to the WCB within ten calendar days from the date of receipt of the PAR determination

Optum preparations
Working closely with the WCB, Optum Workers’ Comp and Auto No-Fault has initiated internal system and process changes to ensure our operations are fully compliant with the new requirements.

Our preparations include:

• Ancillary team is implementing processes to ensure all DMEPOS items that require PAR are authorized prior to providing the item
• Bill Review team will execute changes necessary for retrospective bill review

We urge all clients to ensure their connectivity with the New York OnBoard system and provide the WCB the required information on their entity or point of contact for PAR review requests. 

As our Public Policy and Regulatory Affairs team monitors this developing process, we will continue to clarify the new DMEPOS fee schedule and various provider/payer requirements as they come forward. 

Please feel free to reach out to our team on this or other policy issues at OWCAPolicyMatters@optum.com