What Board forms are to be utilized by medical providers to report treatment rendered within the Guidelines?

  • The C-4 family of forms should be used to report all treatment rendered by physicians, chiropractors and podiatrists. Special Medical Treatment Guidelines forms are only utilized if the medical provider is requesting a variance or optional prior approval.

What Board form is utilized for requesting optional prior approval?

  • Form Form MG-1 must be utilized. In addition, form MG-1.1 can be completed and included with an MG-1 if the medical provider is requesting optional prior approval for additional treatment(s) or procedure(s) in the same case.

What Board form is utilized for requesting a variance?

  • Form MG-2 must be utilized. In addition, form MG-2.1 can be completed and included with an MG-2 if the medical provider is requesting variance(s) for additional treatment(s) or procedure(s) in the same case.

Pre-Authorization

Do the procedures recommended by the Medical Treatment Guidelines require pre-authorization if the cost exceeds the $1,000 threshold?

  • With limited exceptions that are clearly noted in the Guidelines, the testing and treatment that is provided in the Guidelines is pre-authorized. Therefore, the $1,000 pre- authorization threshold does not apply and consent by the insurance carrier will no longer be required. Health care providers are able to treat without pre- authorization, so long as the care is consistent with the Guidelines. A list of procedures specifically identified in the Guidelines, and a repeat of a surgical procedure that has failed or an earlier surgical procedure has had incomplete success requires pre-authorization. The procedures are as follows:
    Lumbar fusions
    Artificial disk replacement
    Vertebroplasty
    Kyphoplasty
    Electrical bone growth stimulators
    Spinal Cord Stimulators
    Anterior acromioplasty of the shoulder
    Chondroplasty
    Osteochondral autograft
    Autologous chondrocyte implantation
    Meniscal allograft transplantation
    Knee arthroplasty (total or partial knee joint replacement)
    The repeat performance of a surgical procedure due to failure of, or incomplete success from the same surgical procedure performed earlier, and if the medical treatment guidelines do not specifically address multiple procedures.

For the procedures within the Guidelines that require pre-authorization, how do medical providers request it?

  • The request for pre-authorization should be made by completing the revised C-4AUTH form and submitting it to the insurance carrier and the Workers’ Compensation Board.

When performing an arthroscopy, sometimes the doctor does not know whether or not a chondroplasty or acromioplasty is needed until the arthroscopy is completed. The arthroscopy is pre-authorized under the Guidelines, however the chondroplasty or acromioplasty are not. Should the physician request authorization for every arthroscopy in the event a chondroplasty or acromioplasty is needed?

  • If, in making a determination regarding surgery, the surgeon believes that a chondroplasty or acromioplasty or other procedure requiring pre-authorization may be necessary, the surgeon should obtain pre-authorization for those procedures. The indication or reasoning for the potential for these requests should be clearly stated.

When a surgeon obtains approval for a procedure not on the pre-approved list, and prescribes physical therapy following the guidelines, does physical therapy require pre-authorization from the insurance carrier?

  • Physical therapy consistent with the Guidelines does not require prior authorization. For physical therapy to continue beyond what is recommended in the Guidelines, the treating medical provider would have to request a variance, and the therapy may continue if the variance request is approved by the carrier or the Board.

The Guidelines indicate that everything is authorized including epidurals and surgery if the Guideline standards are followed, but what happens if the procedure is performed and the insurance carrier later denies payment to the provider or the hospital?

  • Hospital representatives should educate themselves on the Medical Treatment Guidelines. No written authorization is needed when the Guidelines are followed. Treating medical providers may request prior approval from a participating carrier to confirm that the surgery will be reimbursed. If surgery is performed in accordance with the Guidelines, a carrier may not deny payment.

Now that the Medical Treatment Guidelines have been implemented, and a new C-4 Authorization form has been issued in conjunction with this implementation, can older versions of the C-4 Authorization form still be used?

  • The use of the new C-4 Authorization form is encouraged in all cases.

For injuries not currently covered under the Medical Treatment Guidelines does the C-4 Auth process still apply?

  • Yes. WCL § 13-a(5) provides that medical services costing more than $1000 to be valid and enforceable must be authorized by the Board or carrier. Any denial of such medical service must be within 30 calendar days from receipt of the request and “must be based on a conflicting second opinion rendered by a physician authorized by the board.”
    All treatment within the Medical Treatment Guidelines (Guidelines) for the mid and low back, neck, knee, and shoulder and based upon a correct application of the Guidelines are pre-authorized and do not need to go through the C-4AUTH process except for the following 13 procedures: lumbar fusion, artificial disc replacement, spinal cord stimulators, vertebroplasty, kyphoplasty, electrical bone stimulation, anterior acromioplasty, chondroplasty, osteochondral autograph, auto chondrocyte implantation, meniscal allograft transplanation, knee arthroplasty, and second or subsequent performance of a surgical procedure because of a failure or incomplete success (12 NYCRR § 324.2[d]). Those 13 procedures involving the mid and low back, neck, knee, and shoulder and procedures costing over $1000 for all other body parts must follow the C-4 AUTH procedures which requires a written response within 30 days and, in cases of a denial, the submission of “a report offering a conflicting opinion from an independent medical examiner, a qualified medical professional …, or, if the report was made upon a review of the records without a physical examination, a physician authorized to treat workers’ compensation claimants” (12 NYCRR 325-1.4[a]6]).

Does a surgeon need to obtain pre-authorization for repeat surgeries to any body part or only for those body parts covered by the Medical Treatment Guidelines?

  • The prior authorization for repeat surgeries applies to any surgery covered by the 4 Medical Treatment Guidelines (mid and low back, neck, shoulder, knee). For surgery to body parts not covered by the Medical Treatment Guidelines and costing more than $1000, pre-authorization is required.

Prior Approval

Is there anything medical providers can do if they want assurance that their interpretation of the guidelines is correct, or if they need an approval document for a hospital or other entity?

  • Yes. The regulations provide for an optional prior approval procedure where the medical provider can request optional prior approval from a PARTICIPATING insurance carrier to determine correct application of the Guidelines. This process is streamlined and much more limited in focus, and is designed to only answer one question, “is the requested treatment or test a consistent application of the guidelines?” Providers are encouraged to submit the form (MG-1) electronically. Carriers have 8 business days to respond. Disputes are resolved by a binding decision of the Board’s Medical Director’s office. The process allows medical providers to get a reasonably quick determination, and it allows carriers to object to treatments and testing before the procedure has begun. A Board form (MG-1 ) is available for this purpose under the forms section of our website.

Are all insurance carriers and other payer types required to participate in the optional prior approval process?

  • No. This process is only available if the insurance carrier or employer is participating in the optional prior approval program. An insurance carrier who is not participating is not required to respond to an Optional Prior Approval request. A list of insurance carriers and employers who have opted out of the optional prior approval process is available on the Board’s web site.

Can the insurance carrier obtain an IME or records review upon receiving a request for optional prior approval?

  • No. The insurance carrier must approve or deny the request based upon a review of the medical documentation to determine if the test or procedure is a consistent application of the Guidelines.

Can a request for Optional Prior Approval and a Variance request be submitted at the same time?

  • Yes, however when multiple requests for Medical Guideline processes are received that are all integral to a primary procedure request, but have different carrier response timelines, the timeframe for all requests is extended to that of the request with the longest timeline to a maximum of 15 calendar days if there is no IME or 30 calendar days if IME is requested.

Variance Process

Does a medical provider have an option if he or she believes an injured worker needs treatment that is not consistent with the Guidelines?

  • It is recognized there are legitimate reasons for not adhering to the Medical Treatment Guidelines: Extend duration of treatment when a patient is continuing to show objective functional improvement. Individual circumstances, such as other medical conditions, may delay an individual’s response to treatment, or make certain treatment appropriate. Actual treatment is not addressed by the Guidelines. Peer reviewed studies may provide evidence supporting new/alternative treatments. In those cases, the Treating Medical Provider may submit a variance request on form MG-2.

Can the insurance carrier request an IME or records review upon receipt of a variance request?

  • Yes. The variance process does allow an additional amount of time (up to a total of 30 days) for the carrier to have an independent medical exam or record review as long as the insurance carrier notifies the provider and the Board within 5 days of a variance request that an independent medical exam or record review is being conducted.

Can physical and occupational therapists request a variance?

  • No. The request for additional therapy can only be made by the treating medical provider.

Can a physical or occupational therapist complete the MG-2 form, send it to the treating physician for signature, and then submit the request to the appropriate parties?

  • Yes. A physical therapist may complete the MG-2/MG-2.1 form(s) including the Guideline reference codes and supportive documentation of objective findings, and submit it to the treating medical provider for review, approval and signature. Once the treating medical provider approves and signs the form(s), the physical therapist may submit the completed MG-2/MG-2.1 form(s) on behalf of the treating medical provider. The completed MG-2 form must be submitted to the insurance carrier or self-insured employer, the Workers’ Compensation Board, and the claimant’s legal counsel, if any, or to the claimant if not represented.

How long does the insurance carrier have to respond to the request if the review is performed by its medical professional?

  • Upon receiving a variance request, an insurance carrier has three options for obtaining a medical opinion about such request, which are: 1) an IME; or 2) a review of records; or 3) the insurance carrier’s medical professional. If the insurance carrier has a variance request reviewed by its medical professional, it must respond to such request within 15 calendar days of receipt of the request (12 NYCRR §324.3[b][2][i]). If the insurance carrier decides to obtain an IME or review of records to respond to a variance request, it must notify the Chair within 5 business days of such decision and respond within 30 calendar days of receipt of the request (12 NYCRR §324.3[b][2][ii]).

Are medical providers permitted to request review of a variance request denial on behalf of the claimant?

  • No. The claimant and/or the claimant’s legal representative are the only parties who may request review of a carrier’s denial of a variance request.

What is the process for a claimant to file for review from a denial of a variance? Is there a form the claimant must use to request such review?

  • The claimant or the legal representative must complete Section F of the Attending Doctor’s Request for Approval of Variance and Carrier’s Response (MG-2) form and send it to the Board within 21 business days of receipt of the denial of the variance.

Can medical providers provide treatment that is not consistent with the Medical Treatment Guidelines without obtaining a variance?

  • No. The Medical Treatment Guidelines are the standard of care in New York State. If one wishes to provide medical treatment that is not consistent with the Medical Treatment Guidelines, the treating medical provider must seek a variance from the carrier. If the variance is not approved by the carrier or by the WCB, then the treatment is not authorized and should not be provided.

Does a physical therapist keep the patient on program or discharge care while waiting for the status of the variance request?

  • The treating medical provider or therapist should initiate the variance request as early in the treatment program as possible and avoid waiting until treatment is complete, if it is clinically appropriate. According to the Medical Treatment Guidelines regulations, “When a Treating Medical Provider determines that medical care that varies from the Medical Treatment Guidelines, such as when a treatment, procedure, or test is not recommended by the Medical Treatment Guidelines, is appropriate for the claimant and medically necessary, he or she shall request a variance from the insurance carrier or Special Fund by submitting the form prescribed by the Chair for such purpose. A variance must be requested before medical care that varies from the Medical Treatment Guidelines is provided to the claimant and a request for a variance will not be considered if the medical care has already been provided”.

What makes an MG-2 form complete?

  • All Board forms should be completely filled out with all available information. Certain information is essential to the Board’s internal procedures. Without that essential information, the Board cannot process the form. In order for the Board to take action on an MG-2 form, the Board requires that the following fields be completed.
    Section A:
    (1) Patient’s name, and
    (2) Insurance Carrier’s Name & Address.
    Please note that the Insurance Carrier’s or TPA’s name and address must match the information the Board has on file.
    Section B:
    (1) Individual Provider’s WCB Authorization Number for all providers authorized by the New York State Workers’ Compensation Board
    Section C:
    (1) Date Variance Request Submitted and Method of Transmission,
    (2) Guideline Reference for the body part followed by the 2 to 4 character corresponding reference in the Medical Treatment Guidelines or followed by the four letters N-O-N-E if there is no listed procedure,
    (3) Approval Requested For requires a written description of the treatment requested,
    (4) Statement of Medical Necessity requires a description directly on the form and if there is a supporting medical report in the Board’s case file, enter the date of service or if there is no supporting medical report in the case file, attach a medical report and enter “See attached medical report” on the form. The doctor must demonstrate objective functional improvement if requesting physical therapy or chiropractic care.
    (5) A check box selected for how the carrier was contacted. Please note if you listed your fax number at the top of the form, do not select the second check box; and
    (6) the Provider’s signature or stamp. Please note that initials next to the signature or stamp are not acceptable.

If durable medical equipment is not addressed in the Guidelines, is a variance request required in order for the item to be supplied to the injured worker?

  • Yes. A variance request would be required if the durable medical equipment is not addressed in the Guidelines.

If 8 weeks of treatment is recommended under the Guidelines, does the patient have to been seen during consecutive weeks within that 8 week period, or can the weeks be broken up due to patient no-shows, cancellations, vacations, or illness?

  • No. The duration time frames that are recommended in the Guidelines are consecutive. If the recommended duration time frame is 8 weeks, then treatment beyond the 8 weeks would require a variance request.

Existing Claims

Will claimants on long term narcotics and other pain medications have their medications discontinued because of the recommendations in the Medical Treatment Guidelines?

  • No. Claimants who have been receiving long term narcotics and/or other pain medications prior to December 1, 2010 should continue to have their prescriptions paid for by carriers and filled by pharmacies. The Medical Treatment Guidelines allow for the use of pain medication beyond the maximum duration of two weeks. See Subject Number 046-457 dated December 1, 2010.

What if the claim is several years old and the injured worker has already received more than the recommended amount of physical therapy treatment? Do the Guidelines apply?

  • Yes, however the Guidelines apply prospectively. Therefore, the Guidelines’ recommended limits apply to treatments on, or after, December 1, 2010. For example, if the doctor prescribes six weeks of physical therapy two times per week in mid-November, the portion of that therapy that occurs before December 1, 2010 is not subject to the Medical Treatment Guidelines. Beginning December 1, 2010, physical therapy may continue for up to 3 weeks and then, as required in the general principles of the Guidelines, the injured worker must be re-evaluated to determine if there is continuing objective functional improvement. Subsequent physical therapy must be consistent with the Guidelines or be approved through the variance process.

What if the claim is several years old and the injured worker has already received more than the recommended amount of chiropractic treatment? Do the Guidelines apply?

  • Yes. For example, an injured worker has been receiving chiropractic treatment 2 times per month for over a year prior to December 1, 2010. As of December 1, 2010, the Medical Treatment Guidelines apply, therefore the injured worker must be evaluated at the end of a 3 week period to determine if there is continuing objective functional improvement. If the injured worker shows no objective functional improvement, additional chiropractic treatment would not be consistent with the Medical Treatment Guidelines.

If a procedure or test that requires pre-authorization was approved by the insurance carrier prior to December 1, 2010, but the procedure or test cannot be scheduled until after December 1, 2010, does the procedure or test have to comply with the Medical Treatment Guidelines?

  • No. Any procedure or test that has been pre-authorized by the carrier, by an Order of the Chair, or deemed authorized due an untimely response from the insurance carrier, before December 1, 2010, can be performed and will be compensated, even if it does not comply with the Guidelines.

If a Workers’ Compensation Law Judge had previously rendered a decision authorizing ongoing or symptomatic treatment, would the treatment have to follow the Medical Treatment Guidelines?

  • Yes. The Medical Treatment Guidelines apply to cases with orders for ongoing or symptomatic treatment as necessary. If such treatment is not consistent with the Medical Treatment Guidelines, the carrier may object. If treatment exceeds the amount recommended under the Guidelines, the treating medical provider must show that there is a need for continuing treatment through the variance process.

Which Carrier?

Which carrier(s) must respond to Medical Treatment Guidelines (MTG) forms regarding provider requests for variances and optional prior approvals in claims involving Medical Treatment Guidelines where it has not yet been decided which carrier(s) is/are liable for payment?

  • The primary carrier. Regarding claims involving Medical Treatment Guidelines where it has not yet been decided which carrier(s) is/are liable for payment, the Board will designate one carrier as the primary carrier on the Board file who will be solely responsible for responding to medical treatment and/or authorization issues pending resolution of carrier liability. Once carrier liability has been determined, the liable carrier will become the primary carrier responsible for handling medical care related to the claim and will assume responsibility for all medical decisions made by the interim primary carrier while carrier liability was in dispute.

Which carrier(s) must respond to Medical Treatment Guidelines (MTG) forms regarding provider requests for variances and optional prior approvals in claims involving Medical Treatment Guidelines where multiple carriers have been deemed liable for payment?

  • All carriers involved in the apportionment of liability must respond. Regarding claims involving Medical Treatment Guidelines where multiple carriers have been deemed liable for a claim, each carrier is assigned a percentage of the liability for medical treatment, compensation payments to the claimant or both. The medical provider will need to review the Board’s Notice of Decision to determine the carrier liability as each case will have a different percentage allotment. If the medical provider has not received a copy of the Notice of Decision, or has questions regarding the determination of liability they should contact the Board for assistance.

Billing & Payment

Can an injured worker voluntarily pay a medical provider for medical treatment that is not recommended in the Medical Treatment Guidelines?

  • No. Injured workers cannot pay for medical treatment for workers’ compensation injuries or illnesses.

What recourse does a medical provider have if treatment is rendered in accordance with the Guidelines and does not receive payment or a response from the insurance carrier?

  • If there is no response or payment within 45 days from the date the insurance carrier receives the bill, the medical provider may request an Administrative Award on Board form HP-1.

What if the insurance carrier objects to a bill due to Guideline issues?

  • If an insurance carrier objects to a bill stating that the medical treatment was an incorrect application of the Guidelines, was not consistent with the Guidelines, or exceeded the approved variance, a C-8.1 form must be timely filed with the Board and the medical provider. The objection will be decided through the Board’s adjudication process.

If a treating physician does not follow the rules and the carrier is absolved of liability is the claimant responsible for the bill?

  • There is no provision that a claimant is responsible for payment of the treatment when it has been found that the provider improperly billed the carrier and is thus not eligible for an award by the Chair. Pursuant to 12 NYCRR § 325-1.23, , the claimant is responsible for the payment of medical costs in cases in which the claimant fails to prosecute a claim for workers’ compensation or in the event it is determined by the WCB that the illness or condition for which such service was rendered is not the result of a compensable workers’ compensation claim. Additionally, the claimant may become liable for the services rendered in cases where the claim is settled by a Section 32 agreement or in cases in which there is a third party settlement.

Can medical providers provide treatment that is not consistent with the Medical Treatment Guidelines by billing the patient’s group health plan or charging the patient directly?

  • No. The Workers’ Compensation Law prohibits medical providers from charging claimants directly or from billing another health insurance plan for any treatment of an injury that is covered by workers’ compensation.

Diagnostic Networks

Do injured workers still have to obtain diagnostic tests from within a diagnostic network for treatment covered under the Medical Treatment Guidelines?

  • Yes. The Medical Treatment Guidelines have no effect on the insurance carrier’s right to direct an injured worker to their diagnostic network. The MRI must be performed at a network facility if the carrier has contracted with the network facility and if the carrier properly notifies the claimant pursuant to WCL” 13-a(7).

How do the Medical Treatment Guidelines affect radiology facilities?

  • Imaging studies performed to the neck, back, knee, and shoulder will be governed by the Medical Treatment Guidelines effective December 1, 2010. This means that if the study is not consistent with the Guidelines, then the insurance carrier or self-insured employer is not responsible for payment, and the facility cannot bill the claimant.

How is a radiologist with a free standing diagnostic facility or a hospital, who relies on the treating physician’s history and physical examination, supposed to know if the patient’s treating physician has followed the appropriate Medical Treatment Guideline protocols prior to requesting the radiology exam being ordered?

  • The radiologist may wish to contact the treating medical provider and ask if he or she has ordered the study consistent with the Medical Treatment Guidelines for the body part in question. The radiologist may also contact the insurance carrier or self-insured employer to determine if the imaging study is consistent with the Guidelines.

Body Parts Not Covered by the Guidelines

How will injuries to parts of the body not covered by the Medical Treatment Guidelines be handled by carriers?

  • Work related injuries not covered by the Medical Treatment Guidelines will be handled as they have been prior to December1, 2010 according to the existing Workers’ Compensation Board’s rules and regulations. The injuries addressed by the Medical Treatment Guidelines are not the only injuries covered under NYS Workers’ Compensation system.

Out of State Care

If a claimant resides out of state, and is treated by an out of state medical provider, do the various Medical Treatment Guidelines processes such as pre-authorization, variance requests, and option prior approval apply?

  • The Medical Treatment Guidelines and the various Guidelines processes do not apply if the claimant both resides out of state and receives medical treatment out of state.

Do the Medical Treatment Guidelines change the reimbursement methodology for out of state care or the fact that out of state providers are not eligible to request administrative awards or arbitration for unpaid medical bills?

  • The Guidelines do not change the fact that out of state medical providers treating claimants who reside out of state are reimbursed at medical fees customary to the area where the medical services are provided. In addition, the Guidelines do not change the fact that out of state medical providers cannot request administrative awards or arbitration.