What makes an MG-2 form complete?
The MG-2 variance request form is a multi-page document with plenty of small type. Certain information is essential to the Board’s internal procedures and if that information is missing or incomplete, 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 (required items are denoted by the “checklist” symbol “☑“.
Check the MG-2 – if any the following sections are incomplete or missing – issue a denial and alert the Board as to your reasons!
Required in Section A:
☑ Patient’s name, and
☑ 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.
Required in Section B:
☑ Individual Provider’s WCB Authorization Number for all providers authorized by the New York State Workers’ Compensation Board
Required in Section C:
☑ Date Variance Request Submitted and Method of Transmission,
☑ 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,
☑ Approval Requested For requires a written description of the treatment requested,
☑ Statement of Medical Necessity requires a description directly on the form. If there is a supporting medical report in the Board’s case file, the requesting physician should 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;
☑ A check box selected for how the carrier was contacted; and
☑ the Provider’s signature or stamp. Please note that initials next to the signature or stamp are not acceptable.
Also remember that physical therapists are not “medical providers” under the the MTG and cannot issue an MG-2 to request authorization for addiitonal physical therapy visits beyond the Guidelines – only a doctor can issue the MG-2 to request addiitonal PT. Issue a summary denial to any variance request issued by a physical therapist.