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Health Care Providers Insurer Designated Contact for C-4Auth, MG-2, MG-1 Forms

Effective May 2, 2022, Attending Doctor's Request for Authorization and Carrier's Response (Form C-4AUTH), Attending Doctor's Request for Approval of Variance and Carrier's Response (Form MG-2), and Attending Doctor's Request for Optional Prior Approval and Carrier's/Employer's Response (Form MG-1), can no longer be used to request authorization for treatment or testing. Forms submitted prior to May 2, 2022 will be processed in the usual manner, however forms submitted on or after May 2, 2022, will be rejected by the Board.

Health care providers and their delegates will use OnBoard to request treatment/testing prior authorizations. The type of prior authorization request (PAR) will be determined by providing answers to questions based on the treatment/testing needed. Treatment/Testing PARs submitted through OnBoard will automatically be routed to the appropriate claim administrator for review.

Insurer's Designated Medical Treatment Guidelines Contacts, Prior to May 2, 2022

Use the following links to search for information on the insurer's designated medical treatment guidelines contact for any C-4Auth, MG-1 or MG-2 form submitted prior to May 2, 2022.

Note: Typing the Insurer's ID (W#) or name in the search box directly above the table will help to narrow the list.

Contact Us

Please email or call (877) 632-4996 if you have questions regarding this form.