A letter arrives from the insurance carrier. From now on, it says, your MRI has to be done at one of their facilities. Or your prescriptions have to come from their pharmacy. Or you have to treat inside their network.
Sometimes that letter is enforceable. Often it is not. And the thing that usually decides which is not the network at all — it is whether they gave you proper notice, and when.
Start from the default
In New York you may treat with any health care provider authorized by the Workers’ Compensation Board, including your own doctor if they happen to be Board-authorized. In a genuine emergency the authorization requirement does not apply at all. Whether your own doctor is on that list is its own problem — only about ten percent of eligible providers in New York are authorized, and that requirement is being removed on January 1, 2028. See can I use my own doctor for workers’ comp in New York.
Everything below is an exception to that rule. Exceptions have conditions, and the carrier has to meet them.
Diagnostic testing networks, and the DT-1
This is the one most injured workers actually run into, because it covers imaging.
A carrier can contract with a diagnostic testing network and require you to get your testing there — MRI, CT, EMG and nerve conduction studies, diagnostic ultrasound, X-ray. But to do that it has to notify you, and the notice has a name: Form DT-1, “Notice That Claimant Must Arrange for Diagnostic Tests & Examinations through a Network Provider,” or a substantially equivalent document.
- It goes to you and to your treating provider. Both.
- There is a deadline. For existing claims, within fourteen days of the carrier contracting with the network. For new ones, with the statement of rights the carrier has to send you anyway.
And here is the part worth writing down. If the carrier did not send the DT-1, you may get your testing from any Board-authorized provider, and the carrier has to pay for it. The Board states it plainly: where the required notice was not given, the carrier pays for tests done outside the network.
Five ways out even when they did notify you
A valid DT-1 is not the end of it. You can still go outside the network where:
- It is a medical emergency. The carrier cannot demand network testing in an emergency.
- No network provider is within a reasonable distance — and “reasonable” is defined, not argued (see below).
- The network cannot perform the test within five business days. Ask when they can actually schedule you, and write down the answer.
- The carrier has controverted your claim. If they are disputing the claim, they do not also get to direct your testing.
- X-rays taken during an office visit for certain conditions — fractures, dislocations, tumors, infections, problems with surgical implants, spinal instability, or post-surgical follow-up.
The distance limits are fixed:
| Where you are | Reasonable distance |
|---|---|
| New York City — including Staten Island and Brooklyn | 5 miles |
| Other major cities (Albany, Buffalo and the like) | 10 miles |
| Nassau, Rockland, Suffolk, Westchester | 15 miles |
| Everywhere else in the state | 25 miles |
Five miles is the number for our clients, and it is smaller than people assume. If the network facility they are sending you to is across the borough, that is worth measuring before you rearrange your week around it.
Pharmacy networks
The same structure, with the same hinge.
You can use any pharmacy unless the carrier or self-insured employer uses a designated pharmacy, pharmacy network or pharmacy benefit manager — and has told you so. Where you were not notified to use a designated pharmacy and you filled your prescription elsewhere, the carrier is to pay that bill or reimbursement request. Where you were properly notified and went elsewhere anyway, it may not be.
Two practical points:
- A network pharmacy is paid directly. You should not be paying anything at the counter. If a network pharmacy is asking you for money for a medication in an established claim, something is wrong — call us before you pay it.
- There is an emergency exception. You can buy the medication elsewhere where there is a medical emergency and it is not reasonably possible to get what you need immediately.
PPOs: the 30-day rule
A preferred provider organization is the older arrangement, running under Article 10-A of the Workers’ Compensation Law since 1997. Where your employer has one, your initial treatment comes from inside the network.
It is not permanent. After 30 days from your first visit you can go outside the PPO, by giving written notice to your employer or the insurer that you intend to do so. Written, and keep a copy.
A PPO is also supposed to give affected employees written notice of the arrangement, along with a handbook covering how to access services, how to select and change providers, the opt-out procedure, how to get a second opinion, and a full list of participating providers. If you were never given any of that, say so.
One thing that is not a network at all
The doctor the carrier sends you to for an independent medical examination is not a network provider and is not your treating doctor. That examiner is retained by the carrier, writes a report for the carrier, and is not there to treat you.
Attending an IME is a separate obligation. It does not change who treats you.
What to do when one of these letters arrives
- Keep it, with the envelope and the date. When notice arrived is frequently the whole question.
- Check whether your doctor got one too, for diagnostic testing. The notice is supposed to go to both of you.
- Measure the distance before you accept a facility as your only option.
- Ask the network for the soonest appointment and write down what they say. Five business days is a real limit, and nobody will volunteer it to you.
- Do not pay at a network pharmacy counter without asking why you are being charged.
- Do not assume the letter is wrong either. Some of these are perfectly valid, and ignoring a valid one can leave you holding a bill.
More on the ground rules for treatment generally is in our guide on what to do when you are hurt at work, and on what happens when care is refused outright in denied medical treatment.
If you are free to choose your own doctor, our step-by-step guide to finding a workers’ comp doctor walks through searching the Board’s directory and what to ask before you book.
The carrier may also assign a nurse case manager to your claim. That is a different role from choosing your doctor, and you have more say in it than many people realize. See a nurse case manager wants to talk to you: do you have to?
Talk to a New York workers’ compensation attorney
If you have been told you must use a particular facility, pharmacy or doctor and it does not seem right, bring us the letter. Whether it binds you usually turns on details that are on the page in front of you.
Call (718) 701-2776. The consultation costs nothing, and you will speak with me.
We handle workers’ compensation claims for injured workers throughout the five boroughs and across New York State. If we don’t recover money for you, we don’t get paid.
Nothing on this page is legal advice about your own claim. Network rules and the notices that trigger them change, and whether a particular notice was valid is decided on the facts of your case.