Medical Treatment Guidelines
Insurer Requirements

The regulations require insurance carriers to:

• incorporate the Medical Treatment Guidelines into their policies, procedures, and practices and report their compliance to the Workers' Compensation Board;
• designate contacts to assist health care providers with Variance approvals, Optional Prior Approvals and Pre-Authorizations (C-4AUTH forms); and
• pay providers for services rendered in accordance with the Guidelines.

Note: When a variance request is denied, insurers are allowed to select a dispute forum preference (medical arbitrator or WCB adjudication) in each dispute. If either the insurer or injured worker selects resolution through adjudication, the case shall proceed for proposed decision and, if necessary, to a WCB Hearing. If neither selects adjudication, the dispute will be referred to the medical arbitrator. The resolution is binding and not appealable under WCL § 23.

Register for Medical Treatment Guidelines

Insurers are required to complete a registration to assign an administrator and designate contacts for Medical Treatment Guidelines. This includes insurers who contract with a Third Party Administrator (TPA) to administers their claims. A TPA is not permitted to register on an insurer's behalf.

Assign an Administrator

The insurance carrier must designate an administrator from its organization during the registration process. Administrators will be responsible for submitting contact information to the Board and for keeping the contact information updated. If the insurance carrier uses a TPA, the administrator can add designated contacts for their third party administrator.

In addition, the administrator has the authority to opt the insurer out of the Optional Prior Approval process and certify that the insurer has implemented Medical Treatment Guidelines into its policies, practices and procedures.

An insurer may designate more than one administrator, including an administrator from its TPA. For more information, read Administrators Responsibilities.

 

Designated Contacts

Every insurance carrier is required to designate the name, telephone number, fax number and/or email address of at least one qualified employee as a point of contact for the Board and treating medical providers. Contacts will be responsible for the review of requests for variances, optional prior approval and authorization for special service(s) costing over $1,000 in a non-emergency situation or requiring pre-authorization pursuant to the Medical Treatment Guidelines (MTG). Changes in the designated contact must be reported to the Board within 10 business days of the change.

• Variance approvals - Variances allow treating medical providers to request treatment that is not consistent with the MTGs, including requests to extend treatment beyond the maximum duration or frequency recommended in the MTG, or requests for treatment that is not recommended or not addressed in the MTGs. A Variance must be requested and approved before treatment is provided.
• Optional Prior Approvals - The treating medical provider has the option of requesting prior approval from a participating insurance carrier to confirm that the proposed medical care is consistent with the Medical Treatment Guidelines. In addition to sending the optional prior approval request via fax or email, the provider may contact the insurer by telephone.
• Pre-Authorizations -With limited exceptions, care that is provided consistent with MTG recommendations does not require pre-authorization. Pre-authorization is only required for the 11 procedures and second surgeries listed in the Medical Treatment Guidelines for the back, neck, shoulder, knee, carpal tunnel syndrome and non-acute pain. For injuries not covered under the MTGs, pre-authorization must be granted for treatments or procedures costing more than $1,000, in a non-emergency situation.