Under the New York State Workers’ Compensation Board’s Medical Treatment Guidelines a physician must file form C-4AUTH if a recommended surgical procedure is not consistent with the Board’s Medical Treatment Guidelines.
In the vast majority of cases, form C-4AUTH is denied by the insurance carrier. However, many times the carrier has not properly filed their denial.
First, the carrier must approve or deny the requested procedure within 30 days of receipt of the request. This is done by simple checking off the “Granted” or “Denied” box on the C-4AUTH form. In most instances, the insurance carrier will formally deny the procedure within the 30-day timeframe. However, Board Rule 300.23(d) requires that within 5 days after this denial the carrier must file for C-8.1 Part A and attach thereto a medical report demonstrating its basis for denial. This is where many insurance carriers fail to comply with the rules. They don’t file for C-8.1A within 5 days and/or fail to attach a conflicting 2nd opinion. This failure will render their denial defective.
If your physician has requested approval for surgery and it has been denied, make sure that you determine whether or not the denial was properly filed. If not, your surgery may automatically be approved.