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 |