Title: Section 732-1.1 - Definitions

Effective Date

07/16/1997

Section 732-1.1 Definitions. The following terms, as used in this Part, shall have the following meanings:

(a) "Carrier" or "insurer" shall mean the insuring, risk bearing entity which contracts with the employer and the PPO for the provision of workers' compensation medical and service benefits.

(b) "Chair" shall mean the Chair of the Workers' Compensation Board

(c) "Claimant" shall mean an individual employed by or otherwise covered for workers' compensation benefits by a participating employer and eligible for medical care provided by a PPO who receives treatment for or applies for medical and/or health services for any accidental injury arising out of and in the course of employment or for occupational disease.

(d) "Commissioner" shall mean the Commissioner of Health.

(e) "Emergency or urgent care" shall mean medical care, treatment, services, products or accommodations provided to an injured or ill employee for a sudden onset of a medical condition of such nature that failure to render immediate care would reasonably result in deterioration of the injured employee's medical condition.

(f) "Governing body" shall mean the board of directors or trustees of a not-for-profit corporation, the officers, directors and stockholders of a business corporation, all partners in a partnership or the individual proprietor of a PPO.

(g) "Preferred Provider Organization" or "PPO" shall mean a plan certified pursuant to the requirements of this Subpart owned, operated or administered by an entity that provides or arranges for the coordination and delivery of all services required by subdivision (h) of this section to all persons covered by such plan. No insurer or employer shall have any financial interest in the PPO.

(h) Services provided by a PPO shall include all services provided or arranged for under the Workers' Compensation Law to diagnose, treat and rehabilitate a claimant requiring medical treatment of an occupational disease or an accidental injury arising out of and in the course of employment, which shall include but not be limited to:

(1) inpatient hospital services;

(2) emergency or urgent care services;

(3) primary care physician services;

(4) diagnostic imaging services;

(5) physical therapy, occupational therapy and rehabilitation services;

(6) other therapeutic services;

(7) mental health professional services;

(8) pharmacy services;

(9) specialist services as required by patient conditions and/or authorized under the Workers' Compensation Law.

(10) occupational disease and injury services; and

(11) such other services as may be required by the commissioner to be provided as a condition of certification.

(i) "Service area" shall refer to an area defined on a county by county basis.

(j) "Employer" shall mean an employer covered by the Workers' Compensation Law who is either self-insured or who contracts with an insurer to arrange for coverage for employees for all necessary treatment and care for accidental injury, illness arising out of and in the course of employment or for occupational disease.

(k) "Rural area" shall mean any county not defined as an urban area pursuant to this section.

(l) "Urban area" shall, for the purposes of this Part, mean the following counties: Albany, Bronx, Broome, Chautauqua, Chemung, Dutchess, Erie, Kings, Monroe, Montgomery, Nassau, New York, Niagara, Oneida, Onondaga, Orange, Oswego, Putnam, Queens, Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Suffolk and Westchester.

Volume

VOLUME E (Title 10)

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