The New York State Workers’ Compensation Board (WCB) has today published in the New York State Register its proposed amendments updating its Dental Fee Schedule.  You can read the complete State Register notice below.  New language is underlined and italicized; deleted language is [bracketed and struck through].  Public comment on the proposed regulations ends 60 days from today.

Workers’ Compensation Board

PROPOSED RULE MAKING

NO HEARING(S) SCHEDULED

Dental Fee Schedule

I.D. No. WCB-26-25-00003-P

PURSUANT TO THE PROVISIONS OF THE State Administrative Procedure Act, NOTICE is hereby given of the following proposed rule:

Proposed Action: Amendment of section 444.2 of Title 12 NYCRR.

Statutory authority: Workers’ Compensation Law, sections 117 and 141

Subject: Dental Fee Schedule.

Purpose: To update the dental fee schedule.

Text of proposed rule: Section 444.2 of Title 12 NYCRR is hereby amended to read as follows:

Section 444.2.  Fee Schedule

(a) The dental fee schedule for all dental services shall be the Official New York Workers’ Compensation Dental Fee Schedule, [First] Second Edition, [March 1, 2009] June 17, 2025, prepared by the Chair and published by the Board, which is hereby incorporated by reference, except that the maximum reimbursement for dental services in cases in which the insurance carrier files or has filed a notice of controversy pursuant to Workers’ Compensation Law section 25(2)(a) or (b) shall be 25 percent more than the fees set forth in the Official New York Workers’ Compensation Dental Fee Schedule. Upon resolution of the controverted claim in favor of the claimant, payers shall automatically add 25 percent to any dental bill that was billed in accordance with the Official New York Workers’ Compensation Dental Fee Schedule during the pendency of the controversy. When a dentist knows at the time of submission of a bill that the claim is being controverted, the dentist should use modifier 1C to identify the 25 percent increase, but the 25 percent increase cannot be denied solely because of the absence of modifier 1C on the original bill.

(b) The Official New York Workers’ Compensation Dental Fee Schedule incorporated by reference herein may be examined at the office of the Department of State, 99 Washington Avenue, Suite 650, Albany, NY 12231, the Legislative Library, the libraries of the New York State Supreme Court, [and] the district offices of the Board [in Albany, Binghamton, Brooklyn, Buffalo, Hauppauge, Hempstead, Manhattan, Peekskill, Queens, Rochester and Syracuse,] as well as available for viewing free of charge on the board’s website. [Copies may be obtained from the Board by writing to New York Workers’ Compensation Dental Fee Schedule, Bureau of Health Management, New York State Workers’ Compensation Board, 100 Broadway - Menands, Albany, NY 12241 or by telephone at 1-800-7812362 or by email at general_information@wcb.state.ny.us].

(c) The Official New York Workers’ Compensation [d]Dental [f]Fee [s]Schedule shall be updated by the Chair as he or she deems warranted by changes in market rates. The [d]Dental [f]Fee [s]Schedule consists of a list of Current Dental Terminology (CDT) codes and descriptions of treatment services and procedures as published by the American Dental Association with a corresponding maximum fee to be charged by [dental providers] dentists. Nothing shall prohibit a [provider]dentist from charging a fee that is less than the Dental [f]Fee [s]Schedule.

(d) [Any treatment or procedure provided in connection with a work related injury not specifically contained in the dental fee schedule should be billed using CDT code D9999 “Unspecified Adjunctive Procedure By Report” (BR). The provider should establish a fee consistent in relativity with the other fees listed in the dental fee schedule. Any bill submitted by a dental provider which lists CDT Code D9999 shall be accompanied by a report providing the reasons why such procedure is necessary to treat the injured employee.] Except in emergencies, any procedure or item over $1,000 or represented by CDT Code D9999 (“Unspecified Adjunctive Procedure By Report - BR”) requires a Prior Authorization Request (PAR). Any treatment or procedure provided in connection with a work-related injury not specifically contained in the Official New York Workers’ Compensation Dental Fee Schedule should be billed using CDT code D9999. Any bill submitted by a dentist which lists CDT Code D9999 shall be accompanied by an additional report providing the reason(s) why such procedure is necessary to treat the injured employee, and why an existing Dental Fee Schedule code could not be utilized. When billing CDT Code D9999, the dentist should reference a comparable code and pricing from the current Dental Fee Schedule, reflecting a similar amount of work, materials and resources, relative to the procedure being requested or performed.

(e) Inclusion of any particular code in this fee schedule does not guarantee reimbursement for that code. Reimbursement may be dependent on multiple factors, including but not necessarily limited to, causal relationship, clinical necessity and appropriateness of the fees submitted.

(f) Physicians (MD, DO, MBBS) with specialized training such as otorhinolaryngology may on occasion perform procedures whose codes are contained within the Official New York Workers’Compensation Dental Fee Schedule, if such procedures are consistent with their training and scope of practice. In such instances, such physicians may use the applicable codes within the Dental Fee Schedule or the applicable codes within the Surgery section of the Official New York Workers’ Compensation Medical Fee Schedule.

Text of proposed rule and any required statements and analyses may be obtained from: Courtney Vallee, Workers’ Compensation Board (Office of General Counsel), 328 State Street, Schenectady, NY 12305, (518) 486- 9564, email: regulations@wcb.ny.gov

Data, views or arguments may be submitted to: Same as above.

Public comment will be received until: 60 days after publication of this notice.

This rule was not under consideration at the time this agency submitted its Regulatory Agenda for publication in the Register.

Regulatory Impact Statement

1. Statutory Authority: Workers’ Compensation Law (WCL) § 117 and § 141 authorizes the Chair of the Workers’ Compensation Board (Board) to adopt reasonable rules consistent with the provisions of the WCL.

2. Legislative Objectives: The proposed amendments update the Board’s dental fee schedule to make it more comprehensive and to update the fees throughout from when it was first adopted in 2009.

3. Needs and Benefits: After a thorough analysis of the current dental fee schedule, the Board has determined that the fee schedule needs updating – many of the fees are outdated, and the dental fee schedule has not been updated since it was first adopted.  Additionally, several new Current Dental Terminology (CDT) codes are proposed to be included, and several old codes deleted.  Language has also been added making explicitly clear that reimbursement is dependent on multiple factors, including causal relationship, clinical necessity, and appropriateness of the fees submitted, in order to safeguard against unnecessary procedures and ensuring quality care for injured workers.  Updating the dental fee schedule conforms to the CDT codes currently in use (as opposed to 15 years ago), provides fairer compensation for dentists treating injured workers and helps ensure higher participation in the workers’ compensation system.  It also contributes to higher quality care for injured workers by reflecting the changes in the dental field over the last 15 years since it was adopted.

4. Costs: There are no additional costs expected as a result of this proposal – the process for prior authorization will be electronic and available with no additional required costs.  The updating of the fees may increase the costs paid by insurers for certain codes, but this should be balanced by deleted codes and an updated fee schedule overall.  Furthermore, it is anticipated that by making the list more comprehensive and updating it for the first time in over fifteen years, that frictional costs associated to fees for dental treatment and unpaid bills will be greatly reduced, if not eliminated.

5. Local Government Mandates: Municipalities or governmental agencies that are self-insured are required to comply with the fee schedule but there are no specific local government mandates associated with this proposal.

6. Paperwork: No new paperwork will be required as a result of this proposal – this is updating the existing fee schedule.

7. Duplication: There is no duplication of State or federal regulations or standards.

8. Alternatives: An alternative would be to not update the dental fee schedule.  However, the Board ultimately decided to provide for these changes to reflect the changes over the last 15 years to ensure dentists are compensated fairly and to help ensure the availability of dentists to treat injured workers.

9. Federal Standards: There are no applicable federal standards.

10. Compliance Schedule: The proposed regulation is mandatory.  All affected carriers and self-insured employers will need to use the proposed changes to the fee schedules.  All parties will have time to make adjustments prior to the proposal’s effective date, which should be upon publication of a Notice of Adoption in the State Register.

Regulatory Flexibility Analysis

1. Effect of rule

The proposed regulation updates the existing dental fee schedule, which has not been updated since it was first adopted in 2009.  The dental fee schedule must be used for all dental treatment provided to workers’ compensation claimants.

2. Compliance requirements

The proposal updates the existing dental fee schedule – it applies to relevant treatment in all workers’ compensation claims.

3. Professional services

It is believed that no professional services will be needed by small businesses or local governments to comply with the proposed regulation.

4. Compliance costs

There are no additional costs expected as a result of this proposal – this is updating the existing dental fee schedule.  The updating of fees may increase costs paid by insurers for certain codes, but should be balanced by deleted codes and an updated fee schedule overall.  Furthermore, it is anticipated that by making the fee schedule more comprehensive and updating it for the first time in over 15 years, that frictional costs associated to fees for dental treatment and unpaid bills will be greatly reduced, if not eliminated.

5. Economic and technological feasibility

Compliance with the proposal is economically and technologically feasible for small businesses and local governments.  The dental fee schedule already exists – this is updating it to account for changes over the last 15 years.

6. Minimizing adverse impact

The proposed regulations were written after a thorough analysis of the current dental fee schedule and the updated Current Dental Terminology (CDT) codes, etc. over the last 15 years since it was last updated.  The Workers’ Compensation Board (Board) proposed these changes to implement a fairer, updated dental fee schedule to also help ensure availability of dental treatment for injured workers when it is needed.

7. Small business and local government participation

The Board does not have a small employer or municipality database, but has sent an electronic communication describing the proposal to approximately 10,300 subscribers for Board updates (health care providers and employers).  The Board will also duly consider all public comments received from small businesses or local governments during the public comment period.

Rural Area Flexibility Analysis

1. Types and estimated numbers of rural areas

The proposal updates the dental fee schedule which has not been updated since it was first adopted in 2009.  The dental fee schedule must be used for all dental treatment provided to workers’ compensation claimants across New York State, including rural areas.

2. Reporting, recordkeeping and other compliance requirements; and professional services

The same compliance and recordkeeping requirements apply to rural areas as metropolitan ones.  This updates the existing dental fee schedule and no special professional services should be required by rural or any other areas.

3. Costs

There are no additional costs expected as a result of this proposal – this is updating the existing dental fee schedule.  The updating of fees may increase costs paid by insurers for certain codes, but should be balanced by deleted codes and an updated fee schedule overall.  Furthermore, it is anticipated that by making the fee schedule more comprehensive and updating it for the first time in over 15 years, that frictional costs associated to fees for dental treatment and unpaid bills will be greatly reduced, if not eliminated.

4. Minimizing adverse impact

The proposed regulations were written after a thorough analysis of the current dental fee schedule and the updated Current Dental Terminology (CDT) codes, etc. over the last 15 years since it was last updated.  The Board proposed these changes to implement a fairer, updated dental fee schedule to also help ensure availability of dental treatment for injured workers when it is needed.

5. Rural area participation

The Board does not have a rural area database, but has sent an electronic communication describing the proposal to approximately 10,300 subscribers for Board updates (health care providers and employers).  The Board will duly consider all public comments received from rural areas during the public comment period.

Job Impact Statement

A Job Impact Statement is not required because the proposed regulation will not have any impact, adverse or otherwise, on jobs or employment opportunities.  The proposed amendments update fees for dental treatment.