Under the New York State Workers’ Compensation Board’s Medical Treatment Guidelines, pre-authorization is not needed for various modalities of treatment specifically referred in the Guidelines. However, certain procedures have been enumerated under Section A.14 of the Guidelines and specifically require pre-authorization. These procedures are listed below:
- Lumbar Fusion
- Artificial Disk Replacement
- Electric Bone Growth Stimulator
- Spinal Cord Osteochondral Autograph
- Autologous Chondrocyte Implantation
- Meniscal Allograft Transplantation
- Knee Arthroplasty (Total or Partial Knee Replacement)
- A repeat surgical procedure due to the first procedure’s failure or incomplete success
Also, your physician may require pre-authorization for special services that cost more than $1,000 in non-emergency situations. These special services are not consistent with the Guidelines, and they may be specifically outlined in the Guidelines.
A physician proposing one of the procedures noted above is required to file a C-4AUTH form in order to properly request authorization. On this form, your physician must provide reasoning for why the requested service is medically necessary.
The form must be submitted to the insurance carrier’s designated contact, which can be found on the Workers’ Compensation Board website. If your physician fails to submit the request to the proper contact, it may be denied. The form must include your WCB case number, the insurer’s case number, your physician’s WCB authorization number, and your doctor’s signature.
In some cases, the claim administrator, which may be with the insurer or a third-party administrator, may ask that an alternate contact be used. In this case, your physician should include the alternate contact’s information on the form and send the pre-authorization request to both the original and alternate contacts.
Finally, your physician should send a copy of the pre-authorization request to the Workers’ Compensation board, your legal representative, if you have one, or to you directly, if you are not represented by an attorney.
Additionally, the C-4AUTH form is used to treat body parts and injuries not covered by the Guidelines. If you are seeking treatment for a work-related injury that is not covered by one of the six available Guidelines, your physician will need to request pre-authorization for services costing more than $1,000.
Securing proper medical treatment under the new Guidelines is extremely difficult to do. It is best to check that your physician has experience with the Guidelines. If your physician is unfamiliar with the Guidelines and pre-authorization procedures, you may experience a delay in receiving appropriate and necessary care.
If you have questions regarding any aspect of your Workers’ Compensation claim, please feel free to contact us.