New York Workers’ Compensation Board Prepares for OnBoard Implementation
On February 3, 2022, the New York Workers’ Compensation Board (WCB) finally responded to the question of, “When will OnBoard Limited Release (OnBoard) go into effect?” Pursuant to a series of Subject Number Bulletins, the answer is, in three phases, the first of which begins on March 7, 2022.
OnBoard Implementation Schedule
|One||Medication PAR & Form HP-1.0||March 7, 2022|
|Two||Durable Medical Equipment PAR||April 4, 2022|
|Three||Treatment/Testing PARs||May 2, 2022
The Optum Workers’ Compensation Public Policy and Regulatory Affairs (PPRA) team has been involved in the long-term development of OnBoard, the Drug Formulary and the DMEPOS fee schedule. To assist our clients, we have summarized the phases of OnBoard implementation and impact to the provision of medical services at each step.
Phase One – March 7, 2022
Drug Formulary Medication Prior Authorization
The first phase of OnBoard implementation will begin with a transition of the pharmacy Prior Authorization Request (PAR) process. The process for requesting, reviewing and responding to a medication PAR is expected to seamlessly transfer from the current Medical Portal process to OnBoard. All providers, payers and reviewing entities will have their current status and processes, including those in-flight, transferred to OnBoard.
With Phase One implementation of OnBoard:
- All prescription medication refills and renewals must comply with the Drug Formulary as of March 7, 2022.
- Medical marijuana treatment for a workers’ compensation claim must be requested via OnBoard via a medication PAR (replacing the MG-2 Variance request and response forms/process).
- Health care providers will request Board action on unpaid medical bills by submitting Form HP-1.0 via OnBoard.
- Payers will not be affected as the processing of Form HP-1.0 after submission will remain the same.
WCB timeline for the transfer of medication PARs to OnBoard:
Friday, March 4, 2022 5:00 P.M. ET
- Current Drug Formulary application within the Medical Portal no longer accessible
- All prior authorization requests in progress as of 5 p.m. will be suspended and converted to a Medication PAR within OnBoard
Monday, March 7, 2022 7:00 A.M. ET
- The Medical Portal process available as “read-only” for review of previously approved medication requests
- Processing will continue within OnBoard
Phase Two – April 4, 2022
Durable Medical Equipment Prior Authorization
The second phase of OnBoard implementation will include application of the new Durable Medical Equipment, Orthotics, Prosthetics and Supplies (DME) fee schedule and associated prior authorization requirements.
The new DME fee schedule (current version adopted December 22, 2021)
- Takes effect for all dates of service on or after April 4, 2022
- Applies to provision of all medical supplies utilized to treat a work-related injury or illness.
- Delinks reimbursement for DME from Medicaid and ties it to a state-specific fee schedule, which contains HCPCS codes for listed items, a description of the item, a reimbursement rate, and a prior authorization indicator
- Requires prior authorization for indicated DME and items not listed in the fee schedule
Much like for medications, providers, vendors and payers will utilize OnBoard to request, review, assign and respond to a PAR for a DME item. Prior to April 4, 2022, providers should take time to familiarize themselves with the DME PAR process and payers or their reviewing entities should ensure they have fully established necessary parameters within OnBoard for review of PAR requests. Within OnBoard:
- Providers will follow directions to submit a request.
- Payers will view submitted requests, assign (via their Work Load Administrator) requests to various individuals or entities, and respond to requests with an approval, partial approval or denial within four calendar days.
- If a provider receives a partial approval or denial, they will have ten calendar days to file a request for an appeal.
More information on specifics related to the DME fee schedule and OnBoard PAR requests can be found here:
DME Fee Schedule and PAR Request FAQ: http://www.wcb.ny.gov/content/main/hcpp/MedFeeSchedules/durable-medical-equipment-faqs.jsp
Phase Three – May 2, 2022
Treatment and Medical Treatment Guidelines (MTG) Variances
The third phase of OnBoard implementation will include initiation of PAR requests via OnBoard for certain medical treatments and testing. Currently, providers and payers use various forms including the C4-AUTH, HP-1, MG-1 and MG-2 to request authorization for medical treatment, testing and variances from the Medical Treatment Guidelines (MTGs). The implementation of OnBoard will eliminate the use of these paper request forms and push prior authorization into the real-time electronic based system.
Utilization of OnBoard by providers for medical services and treatment variance requests will take effect on May 2, 2022. All requests and paper forms submitted before the implementation date will be accepted and continue to follow pre-OnBoard processes.
Providers and payers should review existing MTGs for updates, as well as several new recently-published MTGs set to take effect on May 2, 2022. The MTGs indicate the type of OnBoard request providers are required to submit and how payers respond.
MTG Confirmation PARs will be used to request confirmation from the insurer that the procedure or test is based on a correct application of the MTGs – MG-1 form.
MTG Variance PARs will be used to request testing or treatment that varies from the MTGs applicable to the body part or condition being treated – MG-2 form.
MTG Special Services PARs will be used to request authorization for special service(s), which was previously done using the Attending Doctor's Request for Authorization and Carrier's Response – C-4AUTH form.
Non-MTG Over $1,000 PARs will be used for requests for treatment costing over $1,000 for non-MTG body parts – C-4AUTH form.
Non-MTG Under or = $1,000 PARs (new) will be used for requests for treatment costing $1,000 or less for non-MTG body parts. This PAR type is optional for the health care provider but, if submitted by the provider, a response in OBLR from the payer is mandatory.
Physicians and other treating providers, payers and DME suppliers will need to ensure they are prepared for the coming OnBoard and PAR processes tied to specific treatments and dates.
- Must ensure they are registered and trained in utilizing OnBoard to request PAR for medications, DME and medical treatment variances
- Should communicate immediately with any of their workers’ compensation patients utilizing refill and renewal medications preparing them for impact of the drug formulary
- Should prepare their drug formulary review processes and reviewers to handle PARs on medication refills and renewals
- Should ensure they are fully registered within OnBoard and have made the proper designations, as required by regulation, of their PAR processes, Work Load Administrators and review entities for DME and medical treatment variances
- Should prepare to handle orders or referrals from treating physicians to ensure items requiring PAR are properly handled
- Must secure a NY Medicaid Provider ID within six months from the April 4, 2022 date and begin passing that information through in all DME billing
The New York WCB has provided various educational tools, webinars and other information that can be of great assistance to all impacted stakeholders. In fact, the WCB recently provided bulletins on the implementation of OnBoard that are specific to various groups of stakeholders, which can be found with the following links:
Medical Suppliers: 046-1494
Health Care Providers: 046-1496
Optum Workers’ Compensation and Auto No-Fault Actions
Preparing for OnBoard
Optum Workers’ Compensation and Auto No-Fault (Optum) is moving forward with a myriad of projects to assist our clients in the provision of care via the new OnBoard Limited Release system. Optum has assisted clients in sending communications to both injured persons and their treating physician to alert them of the pending impact of the Drug Formulary on their ongoing medication therapy. As of the date of this notification, Optum has also initiated internal efforts to ensure our pharmacy adjudication systems are updated to the most current drug formulary and the March 7, 2022 requirements.
Optum is also updating our DME systems and procedures around the provision of DME and ancillary medical services to drive compliance with the soon-to-be implemented PAR requirements. Additionally, Optum will secure a Medicaid Provider ID Number to ensure, when necessary, that the proper billing/rendering provider numbers are submitted on New York DME bills.
Finally, our Public Policy and Regulatory Affairs team will continue to work with the WCB during the implementation process to ensure smooth transition for all stakeholders. We will monitor any updates or regulatory changes impacting the rollout of OnBoard and will communicate these to our clients as necessary. Our PPRA team remains available to provide additional insight and education on New York OnBoard Limited Release. Should you have any questions on this content, please reach out to us at OWCAPolicyMatters@optum.com.