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Workers' Compensation Board

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New York State
Workers' Compensation Board
OFFICE OF THE CHAIR
328 State Street  Schenectady, New York 12305
Governor Andrew M. Cuomo


Subject No. 046-1048

Revised Medical Authorization Request Forms

Date: April 6, 2018

What has changed on the medical authorization forms?

The following medical authorization forms:

have been revised to include a place for providers to include their National Provider Information (NPI) number. The forms also expand the certification area by adding a space for more than one fax number or email address. This will allow providers to indicate that the request for authorization was submitted to a second fax number or email address in addition to the designated fax number or email address found on the Board's website. Providers who search the Board's website but cannot locate the designated fax number or email address should check the box "designated contact information not available."

Caution: Medical Providers who submit the form to a fax number or email address other than the designated contact will run the risk of not having the requested treatment authorized.

The MG-2 and MG-2.1 was also revised to allow for a request for denial review to be determined by a medical arbitrator or through WCB Adjudication. If WCB Adjudication is selected, the case will be reviewed to determine if the case is appropriate for a hearing or a proposed decision.

These medical authorization forms can be found under the Health Care Information/Medical Treatment Guidelines page of the Workers' Compensation Board's website. The website has been updated to make it easier to find the proper form and proper designated contact information for the insurer. Please visit Medical Treatment Guidelines for more information.

Medical authorization requests submitted on Forms C-4AUTH or MG-2 must be submitted by one of the following three methods:

  1. A. By fax to the insurer's designated fax number. If the form is also sent to an additional fax number, a space is provided for the physician to indicate the additional fax number; or
  2. B. By email to the insurer's designated email address. If the form is also sent to an additional email address, a space is provided for the physician to indicate the additional email address; or
  3. C. By regular mail with confirmation of delivery (e.g., return receipt requested). If the form is mailed, the physician will provide the date of mailing. Medical providers are permitted to mail the request only if they do not have the technical ability to email or fax the authorization request.

Insurers are required to update the designated contact information posted on the Board's website whenever the fax number, email address or contact information changes. A new web page, Medical Treatment Guidelines Insurer Requirements, has been created to make it easier for insurers to update information. Third-party administrators (TPAs) must notify the insurer or self-insured employer they represent whenever contact information changes so that the carrier's or self-insured employer's administrator can update the TPA contact information listed on the Board's website. The insurer or self-insured administrator may designate more than one administrator, including an administrator from its TPA.

Important: The revised medical authorization request forms dated 4-18 replace earlier versions. Medical providers must submit the latest version of these forms; older versions will be considered obsolete. Obsolete forms received after October 6, 2018 will not be scanned to the case folder.

Medical authorization requests will be screened for accuracy and completeness

The insurer must respond to Forms C-4AUTH, MG-1, MG-1.1, MG-2 or MG-2.1 within the appropriate time frames. If the insurer fails to respond to the authorization request, the special service, the MTG treatment or variance is deemed authorized and the insurer will be liable to pay for the services. If the body part or condition is controverted, payment will not be due until the matter is adjudicated by the Board and a decision is issued with a direction for the insurer to pay for medical treatment rendered pending the outcome of the hearing.

Medical providers may receive a response from the Board in addition to a response from the insurer. Board staff will review authorization request forms for accuracy and completeness and may, if necessary, send notification to the medical provider explaining why the form is incomplete or inaccurate. Orders of the Chair (Form EC-325) indicating that treatment or services requested are deemed authorized may be issued if the insurer does not respond to the written request within the designated time frame. The Board will not issue an Order of the Chair if any of the following exists: 1) the insurer denies the requested treatment within the designated time frame; 2) the form is inaccurate, incomplete, or was submitted on an obsolete version of the form; or, 3) the insurer authorizes the requested treatment.

Authorization requests may be submitted for any claim regardless of whether the claim or body part is accepted by the insurer

Treating medical providers may request authorization for special services or variances regardless of whether the insurer has accepted or controverted a claim, body part or condition. Insurers may select the "granted without prejudice" box only if the claim is controverted or where the insurer has not accepted the body part or condition.

If the Board determines that the insurer is not liable for the body part or condition for which treatment was rendered, the insurer would be relieved of its obligation to pay the medical bill. If the worker's compensation carrier or self-insured employer is found not liable for the bill, the physician may be able to submit the bill to the injured worker's health insurance carrier.

 

Clarissa M. Rodriguez
Chair