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Optional Prior Approval

The new Medical Treatment Guidelines (MTG) are the mandatory standard of care for injured workers regardless of the date of injury. All medical care to the neck, mid- and low back, shoulder and knee must be consistent with the MTG. All medical care required by the MTG is deemed ‘authorized’ by the respondent, with the exception of 13 treatments/procedures which require carrier authorization.

The Optional Prior Approval process allows a medical treatment provider the opportunity to confirm that medical treatment is consistent with the MTG. See N.Y.C.R.R. 324.4. While participation in this process is voluntary, as of the date of this writing all carriers have been “opted in” to this system. In order to ‘opt out’ a carrier or third-party administrator must issue a written notice of the desire to get out, and must give the Chair 60 days notice.

The carrier must provide a qualified employee as a point of contact for the medical providers. The required point of contact information is to be placed on the WCB’s website. Medical providers must submit a written form (Form MG-1 for the first request and Form MG-1.1 for all subsequent requests) and are encouraged to call the qualified employees directly to discuss authorizations.

Medical providers must use Form MG-1. Form MG-1 must be sent using “same day transmission” (either fax or email) to the carrier. The carrier has eight (8) days to respond. The carrier can respond one of three (3) ways:

  1. Grant the request;
  2. Grant the request Without Prejudice; or
  3. Deny the Request.

If the request is denied because the requested medical treatment departs from the MTG, further explanation is not required – the carrier should note which specific MTG section supports the denial. The denial must include the name of the medical professional (and that could be a LPN, PA-C, MD, or RN) who reviewed the request along with the MTG section that supports the denial. However, this medical professional (who reviewed the request on behalf of the carrier) does not have to sign the Form MG-1.

If the request is denied, the medical care provider has 14 days to request a review of the denial. The matter then goes to the Medical Arbitrator who will issue a decision within 8 days. The decision of the medical Arbitrator is not appealable under WCL Section 23.

Please note: if the carrier fails to respond to the ‘Optional Prior Approval Request’ a ‘Notice of Resolution’ will be issued approving the procedure and the carrier loses the ability to challenge the necessity or appropriateness of the treatment later.

This process is only to be used for knee, neck, shoulder, and mid- and low back cases. The claim does not have to be established for this process to be used.

Question about the Optional Prior Approval procedure? Contact Greg Lois.

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