On 3/7/2022, phase 1 of New York’s OnBoard: Limited Release (OBLR) kicked off.? We’ve learned a ton and adapted our process to meet new requirements.
On 2/24/2022, we provided some thoughts on what to expect on 3/7/2022.?
Below is a collection of thoughts and guidance based on our learnings thus far.? And with phase 2 and phase 3 set to kick off in April / May - you can expect plenty more from us.
- The transition to OBLR has created additional claims management decisions for MROs performing Level 1 and Level 2 reviews.? Payers should be sure the MRO has access to the information necessary for not only medical necessity review, but also administrative denials and grants without prejudice.
- Payers are not required to notify the injured employee / attorney for medication PARs.? However, for DME (phase 2) and Treatment / Testing PARs (phase 3), notification will be required.
- Injured employee / attorney notification should occur by downloading the final decision PDF from OBLR and sending it ASAP.
- If a provider requests a brand name medication and the reviewer determines a generic form is available and appropriate, the reviewer may “grant in part” and document that decision.
- If the payer / MRO sends a request for more information to the provider through OBLR, the payer / MRO does not receive a notification email when a response is received.? But, the dashboard status will reflect a response by the provider with a bolded status.
- The Board has reiterated that they generally expect medication weaning issues to be handled outside of OBLR.? We would recommend using the RFA-2 Form (section k.) titled “Opioid Weaning under Non-Acute Pain Guidelines.”
- For DME (phase 2) and Treatment / Testing (phase 3), there will be an auto escalation to Level 2 if the decision is for medical reasons and the decision is either denied or partially granted.? However, if the denial is for administrative reasons, it will not auto escalate to Level 2.
- Due dates no longer have exact times in OBLR.? Each PAR response is due at 11:59 pm ET on the due date.
- Payers can ensure that Level 1 and Level 2 reviewer decisions are relayed to their PBM.? Online user administrators can sign into the admin page.? Under the notification for medication PARs area, you will find “final determination.” Here you can add your PBM’s email. Once complete, the PBM will receive a notification with the patient’s information, the requested medication, and decision status.
- Cost considerations are not a valid reason for denial on medication PARs
