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Workers' Compensation Board

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Forms and Processes

Forms and Processes Associated with Medical Treatment Guidelines
Process Form Title Initiated by Response by and when Response Form Denial review requested by Denial Resolution
Pre-Treatment
Optional Prior Approval MG-1

(MG-1.1 may be attached)
Attending Doctor's Request for Optional Prior Approval and Carrier's/Employer's Response

(Continuation of...above form)
Medical Provider
(not OT/PT)
Carrier – 8 days MG-1 Medical Provider - within 14 days Informal – between MP and Carrier or Medical Director's Office
Variance Request MG-2

(MG-2.1 may be attached)
Attending Doctor's Request for Approval of Variance and Carrier's Response

(Continuation of …above form)
Medical Provider
(not OT/PT)
Carrier – 15 days or, if notify of IME within 5 days, then 30 days MG-2 Injured worker – within 21 days Medical Director's Office unless Carrier or Claimant/Claimant Attorney request an expedited hearing
(Required) Pre-Authorization C-4AUTH Attending Doctor's Request for Authorization and Carrier's Response Medical Provider Carrier – 30 days with IME C-4AUTH automatic Expedited hearing
Post-Treatment
Administrative Award Request HP-1
Part A
Health Care Provider's Request for decision on Unpaid Medical Bill(s) Medical Provider - 45 days after bill if no response N/A HP-2 Carrier may object Disputed Bills Unit
Objection to Bill on MTG Issues C-8.1
Part B
Notice of Treatment Issue(s)/Disputed Bill Issue(s) Carrier WCB Adjudication N/A N/A WCB Hearing or Conciliation
Objection to Bill for Valuation Issues C-8.4 Notice to Health Care Provider and Injured Worker of a Carrier's Refusal to Pay All (or a Portion) of a Medical Bill Due to Valuation Objection(s) Carrier Medical Provider Arbitration Request on HP-1 Part B N/A Arbitration Panel