New York > Workers Compensation
Attending Doctors Request For Optional Prior Approval And Carriers-Employers Response MG-1 - New York
| Attending Doctors Request For Optional Prior Approval And Carriers-Employers Response Form. This is a New York form and can be used in Workers Compensation . |
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ATTENDING DOCTOR'S REQUEST FOR OPTIONAL PRIOR APPROVAL AND CARRIER'S/EMPLOYER'S RESPONSE State of New York - Workers' Compensation Board FOR ADDITIONAL APPROVAL REQUESTS IN THIS CASE, ATTACH FORM MG-1.1 Answer all questions where information is known. MG-1 WCB Case Number: Carrier Case Number: Date of Injury: Social Security No.: A. Patient's Name: First MI Last Patient's Address: Employer's Name & Address: Insurance Carrier's Name & Address: Note: This form is used only if the employer/carrier participates in the Optional Prior Approval program. You can obtain participation status from the WCB Website. B. Attending Doctor's Name & Address: Individual Provider's WCB Authorization No.: Telephone No.: Fax No.: C. DATE REQUEST SUBMITTED: The undersigned requests optional prior approval under the WCB Medical Treatment Guidelines as indicated below: Treatment/Procedure Requested: Guideline Reference: (In first box, indicate body part: K = Knee, S = Shoulder, B = Mid and Low Back, N = Neck, C = Carpal Tunnel In remaining boxes, indicate corresponding section of WCB Medical Treatment Guidelines.) (if not already in file, please attach.) Date of Service of Supporting Medical in WCB Case File: Other Comments: I certify that I am making the above request for optional prior approval and my affirmative statements are true and correct. I did / did not contact the carrier by telephone to discuss this request before making it. I contacted the carrier by telephone on (date) and spoke to (person spoken to or was not able to speak to anyone) . A copy of this form was sent to the carrier/employer/self-insured employer/Special Fund by (fax number or e-mail address required) A copy was sent to the Workers' Compensation Board (see the Board's email address and fax number on the reverse), and copies were provided to the claimant's legal counsel, if any, and to any other parties of interest on the date below. Provider's Signature: Date: D. CARRIER'S / EMPLOYER'S RESPONSE (Response is due 8 business days from receipt of this request or medical care is deemed approved (12 NYCRR 324.4(c)). The provider's request is: Granted Granted without Prejudice (see item 7 on reverse) Denied IF DENIED, STATE THE BASIS FOR THE DENIAL IN THE SPACE PROVIDED BELOW. SEE IMPORTANT INFORMATION TO CARRIER ON REVERSE. Name of the Medical Professional who Reviewed the Denial: I certify that copies of this form were sent to the Treating Medical Provider requesting optional prior approval, the Workers' Compensation Board (see email address and fax number on the reverse), the claimant's legal counsel, if any, and any other parties of interest, on the date below. By: (print name) Signature: Title: Date: E. MEDICAL PROVIDER'S REQUEST FOR REVIEW BY MEDICAL ARBITRATOR OF DENIAL I hereby request review by a medical arbitrator designated by the Chair of the carrier's decision to deny optional prior approval of the above request. I understand that resolution by the medical arbitrator is binding and is not appealable under Workers' Compensation Law §23. (Request is due within 14 calendar days of the date of denial.) Supporting medical report(s) dated is/are attached or is/are available in the WCB case file. Provider's Signature: Date: F. CARRIER / EMPLOYER IS APPROVING THIS REQUEST FOR OPTIONAL PRIOR APPROVAL AFTER AN INITIAL DENIAL I certify that the provider's request for optional prior approval given above, which was initially denied on By: (print name) Signature: Title: Date: THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. , is now granted. MG-1.0 (2-13) www.wcb.ny.gov American LegalNet, Inc. www.FormsWorkFlow.com REQUEST FOR OPTIONAL PRIOR APPROVAL IMPORTANT TO TREATING MEDICAL PROVIDER 1. This form is used for a workers' compensation, volunteer firefighters' or volunteer ambulance workers' benefit case as follows: To request optional confirmation from insurance carrier, self-insured employer, employer or Special Fund that the procedure or test is based on a correct application of the Medical Treatment Guidelines. 2. Treating Medical Providers, which includes any physician, podiatrist, chiropractor or psychologist who is providing treatment and care to an injured worker pursuant to the Workers' Compensation Law, must treat injuries pursuant to the relevant Medical Treatment Guidelines. The Medical Treatment Guidelines are posted on the Board's website. For additional information, please call 1-800-781-2362. 3. The Medical Treatment Guidelines are the standard of care for injured workers. Additional information about the Guidelines, including e-learning training, is available on the Board's website. 4. This form must be signed by the treating medical provider and must contain her/his authorization certificate number and code letters. If the patient is hospitalized, it may be signed by a licensed doctor to whom the treatment of the case has been assigned as a member of the attending staff of the hospital. The signature can be the original or a stamp or an electronic signature as long as the medical provider has the intent to sign the completed form. The provider must review and approve each completed form. Also, someone else cannot sign the medical provider's name. 5. Please ask your patient for his/her WCB case number, if available, and the carrier's case number and show these numbers on this form. In addition, ask your patient if he/she has retained a representative. If patient is represented, ask for the name and address of the representative. This request must be sent to the Workers' Compensation Board, the workers' compensation insurance carrier, selfinsured employer, employer or Special Fund, and, if the patient is represented by an attorney or licensed representative, to such legal representative. If your patient is not represented, a copy must be sent to your patient. 6. If authorization or denial is not forthcoming within 8 business days after the carrier has received the request, the test or treatment is deemed approved and the Board will issue a Notice of Resolution stating the request is approved. 7. If the carrier has checked "GRANTED WITHOUT PREJUDICE" on the front of this form, the liability for this claim has not yet been determined. This authorization is made pending final determination by the Board. Pursuant to 22 NYCRR § 325-1.4(b) this authorization is limited to the question of medical necessity only and is not an admission that the condition for which the serv
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