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Glossary of WCB Terms
New York State
Workers' Compensation Board
OFFICE OF THE CHAIR
328 State Street  Schenectady, New York 12305
Governor David A. Paterson


Subject No. 046-452

Overview of Medical Treatment Guidelines Processes

Date: November 16, 2010

The Medical Treatment Guidelines will become the mandatory standard of care for the mid and low back, neck, shoulder, and knee, effective for dates of service on or after December 1, 2010.

All stakeholders and Board staff will be expected to comply with the regulations. In short, with the exception of certain procedures discussed below, treatment that is consistent with and a correct application of the Guidelines is authorized without requiring prior authorization from the carrier or self-insured employer. Treatment that is outside or in excess of the Guidelines will not be reimbursed unless the treating provider has obtained a variance from the carrier, self-insured employer or the Board.

Treating Medical Provider

Treating Medical Provider, as defined by the regulations, means any physician, podiatrist, chiropractor, or psychologist that is providing treatment and care to an injured worker pursuant to the Workers' Compensation Law. The Medical Treatment Guidelines also require that physical therapists and occupational therapists adhere to Guideline requirements, although they are not included in the definition of Treating Medical Provider and therefore cannot request an optional prior approval or a variance.

Optional Prior Approval

The optional prior approval process allows a Treating Medical Provider to request a determination from a participating carrier that the planned medical treatment is consistent with the Guidelines. Insurance carriers that participate in the optional prior approval process must designate a qualified employee as a point of contact for the Board and Treating Medical Providers. The new forms for the Optional Prior Approval process are:

  • MG-1, Attending Doctor's Request for Optional Prior Approval and Carrier's/Employer's Response; and
  • MG-1.1, Continuation to Form MG-1, Attending Doctor's Request for Optional Prior Approval.

Carriers must respond to an Optional Prior Approval request on the same form used by the Treating Medical Provider to request the approval. The carrier has eight business days to respond. The carrier may grant authorization without prejudice when the compensation case is controverted or the body part has not yet been established. Such authorization shall not be an admission that the condition for which these services are required is compensable or the employer/carrier is liable. If the request is denied, the Treating Medical Provider has 14 calendar days to request a review by the medical arbitrator. The medical arbitrator will render a decision within eight business days of the Treating Medical Provider's request for review. This decision is binding and may not be appealed. If the carrier fails to respond to the request within the 8 business days, the medical care is deemed approved.

The Optional Prior Approval Request Process Flow can be found on the Board's website by selecting Medical Treatment Guidelines and then selecting References. The following link is also being provided.

http://www.wcb.ny.gov/content/main/hcpp/MedicalTreatmentGuidelines/Training/opaflow.pdf adobe pdf

Treatment Pre-authorization

With few exceptions, all treatment in accordance with the Guidelines is pre-authorized, whether the cost exceeds $1,000 or not. The exceptions include twelve specific procedures listed in the Medical Treatment Guidelines and any second or subsequent performance of a surgery due to the failure or incomplete success of the same surgical procedure performed earlier. These procedures require the use of Form C-4AUTH to obtain authorization. Note: Treatment and procedures exceeding $1,000 that are a correct application of the guidelines are preauthorized and do not require the use of Form C-4AUTH.

The regulations require carriers to pay providers for services rendered in accordance with the Guidelines. Treatment that is outside the Guidelines will not be reimbursed unless a variance request is first approved by the carrier or the Board.

Variances

Variances provide flexibility by allowing Treating Medical Providers to request approval for treatment that varies from the Guidelines. Variance requests are used in the following circumstances:

  • To extend duration of treatment when an injured worker is continuing to show objective functional improvement;
  • To treat outside the Medical Treatment Guidelines; or
  • For treatment not addressed by the Medical Treatment Guidelines.

The new forms for the Variance process are:

  • MG-2, Attending Doctor's Request for Approval of Variance and Carrier's/Employer's Response; and
  • MG-2.1, Continuation to Form MG-2, Attending Doctor's Request for Approval of Variance

The Treating Medical Provider must provide medical justification that supports the variance request.The carrier must respond to a variance request on the same form used by the Treating Medical Provider to request the variance. The carrier has 15 calendar days to respond to the variance request if the carrier does not intend to obtain an IME or a medical records review. If the carrier intends to obtain an IME or a medical records review, the carrier must respond within 5 business days, and then approve or deny the variance request within 30 calendar days. If the request is denied, the injured worker may request a review of the denial within 21 business days of receipt of the denial. Upon receiving the injured worker's timely request for review, the Board will schedule an expedited hearing within 30 days, unless both the carrier and the injured worker agree to have the dispute resolved by a binding decision of the medical arbitrator. The decision of the medical arbitrator cannot be appealed.

The Variance Request Process Flow can be found on the Board's website by selecting Medical Treatment Guidelines and then selecting References. The following link is also being provided.

http://www.wcb.ny.gov/content/main/hcpp/MedicalTreatmentGuidelines/Training/varianceflow.pdf adobe pdf

New and Revised Forms

Samples of the new and revised Medical Treatment Guideline forms are available on the website (http://www.wcb.ny.gov/content/main/hcpp/MedicalTreatmentGuidelines/MTGForms.jsp). PDF versions of the new and revised forms without the "DO NOT FILE" watermark are available by request (formsdepartment@wcb.ny.gov) for those that want to incorporate the forms into their systems. Providers in the temporary shortage area (Subject Number 046-398) will be required to use the Medical Treatment Guideline forms. This includes Form C-4 AUTH. Providers and Carriers will be expected to use the forms on or after December 1, 2010, unless the revisions to the existing forms were instructional only.

Please contact the Board's Bureau of Health Management at (800) 781-2362 if you have any questions. Additional information and free e-learning (Subject Number 046-445) on the Guidelines may also be found on the Board's web site under Board Announcements at www.wcb.ny.gov.

Thank you for your cooperation.

 

Robert E. Beloten
Chair