IMPORTANT: PLEASE READ CAREFULLY THE FOLLOWING INFORMATION FOR DETERMINING HOW TO FIND INSURER/SELF-INSURER CONTACTS MG-1, ATTENDING DOCTOR'S REQUEST FOR OPTIONAL PRIOR APPROVAL AND INSURER'S/EMPLOYER'S RESPONSE This form requires the name and fax number or email address of the insurer's designated contact listed on the Workers' Compensation Board's website. Insurer/Self-Insurer's designated contact information is available online at: wcb.ny.gov/medical-treatment-guideline-optional-prior-approval MG-1.0 (4-18) COVER SHEET(In first box, indicate injury and/or condition: K = Knee, S = Shoulder, B = Mid and Low Back, N = Neck, C = Carpal Tunnel, P = Non-Acute Pain. In remaining boxes, indicate corresponding section of WCB Medical Treatment Guidelines.) Patient's Name:The undersigned requests optional prior approval under the WCB Medical Treatment Guidelines as indicated below: Guideline Reference:(Attach if not already submitted.) A copy was sent to the Workers' Compensation Board (see the Board's email address and fax number on the reverse). I certify that I am making the above request for authorization. This request was made to the insurer/self-insurer using the following means of same-day transmission (A or B): INSURER'S / EMPLOYER'S RESPONSE (Response is due within 8 business days of receipt of this request or medical care is deemed approved (12 NYCRR 324.4(c)). The provider's request is: 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). INSURER / EMPLOYER IS APPROVING THIS REQUEST FOR OPTIONAL PRIOR APPROVAL AFTER AN INITIAL DENIAL ATTENDING DOCTOR'S REQUEST FOR OPTIONAL PRIOR APPROVAL AND INSURER'S/EMPLOYER'S RESPONSE FOR ADDITIONAL APPROVAL REQUESTS IN THIS CASE, ATTACH FORM MG-1.1 Answer all questions where information is known. MG-1MG-1.0 (4-18) C.D.E.F. DATE REQUEST SUBMITTED: Treatment/Procedure Requested: IF DENIED, STATE THE BASIS FOR THE DENIAL IN THE SPACE PROVIDED BELOW. SEE IMPORTANT INFORMATION FOR INSURER ON REVERSE. I certify that the provider's request for optional prior approval given above, which was initially denied on, is now granted. Granted Granted without Prejudice (see item 7 on reverse) Denied Individual Provider's WCB Authorization No.:-B.A.First MI Last Employer's Name & Address: Insurer's Name & Address: Social Security No.: Attending Doctor's Name & Address: Fax No.: Telephone No.: Patient's 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. 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 insurer'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 24723. (Request is due within 14 calendar days of the date of denial.) Supporting medical report(s) datedis/are attached or available in the WCB case file. Provider's Signature: Date: Date: Title: By: (print name) By (print name): Title: Signature: Date: Provider's Signature: WCB Case #: Date of Injury/Illness: Claim Administrator Claim (Carrier Case) #: Name of the Medical Professional who Reviewed the Denial: Comments: Date of Service of Supporting Medical in WCB Case File: - NPI No.: Date: Signature: Designated contact information not available. A.Insurer's designated fax # or email address as provided on the Board's website: B.If the request was also submitted to another fax # or email address provided by the insurer, provide here:Provider must enter in A the designated fax or email address this request was sent to. Insurer/self-insurer's designated contact information is available online at: wcb.ny.gov/medical-treatment-guideline-optional-prior-approval. Check "Designated contact information not available", if appropriate. If the request was sent to a different (contact information is not available on Board's website) or additional fax or email address provided by the insurer, complete B. MG-1.0 4-18IMPORTANT TO TREATING MEDICAL PROVIDERMG-1.0 (4-18) Reverse1.This form is used for a workers' compensation, volunteer firefighters' or volunteer ambulance workers' benefit case as follows: Torequest optional confirmation from the insurer, self-insured employer, employer or Special Fund that the procedure or test is based ona correct application of the Medical Treatment Guidelines.2.This form must be signed by the treating medical provider and must contain her/his authorization number and code letters. Out-of-Statemedical providers must enter their NPI number. If the patient is hospitalized, it may be signed by a licensed doctor to whom thetreatment of the case has been assigned as a member of the attending staff of the hospital. The signature can be the original or astamp or an electronic signature as long as the medical provider has the intent to sign the completed form. The provider must reviewand approve each completed form. Also, someone else cannot sign the medical provider's name.3.Please ask the patient for his/her WCB case number, if available, and the claim administrator claim (carrier case) number and showthese numbers on this form.4.Provider must enter in A the designated fax or email address this request was sent to. Insurer/self-insurer's designated contactinformation is available online at: wcb.ny.gov/medical-treatment-guideline-optional-prior-approval . Check "Designated contactinformation not available", if appropriate. If the request was sent to a different (contact information is not available on Board's website)or additional fax or email address provided by the insurer, complete B. Failure to submit the request to the designated contactidentified on the Board's website may result in your request being denied. A copy should also be sent to the Board on the sameday using one of the prescribed methods of same day transmission.5.If authorization or denial is not forthcoming within 8 business days after the insurer has received the request, the test or treatment isdeemed approved and the Board will issue a Notice of Resolution stating the request is approved.6.If the insurer has checked "GRANTED WITHOUT PREJUDICE" on the front of this form, the liability for this claim has not yet beendetermined. This authorization is made pending final determination by the Board. Pursuant to 12 NYCRR 247 324.4(d) this authorizationis limited to the question of medical necessity only and is not an admission that the condition for which the services are required iscompensable. This authorization does not represent an acceptance of this claim by the insurer, self-insured employer, employer orSpecial Fund or guarantee payment for the services authorized. When a decision is rendered regarding liability, you will receive aNotice of Decision by mail. The insurer, self-insured employer, employer or Special Fund will only provide payment for these services ifthe claim is established and the insurer, self-insured employer, employer or Special Fund is found to be responsible for the claim. 7.Treating Medical Providers, which includes any physician, podiatrist, chiropractor or psychologist who is providing treatment and careto an injured worker pursuant to the Workers' Compensation Law, must treat injuries pursuant to the relevant Medical TreatmentGuidelines. The Medical Treatment Guidelines are posted on the Board's website. For additional information, please call (800)781-2362.8.The Medical Treatment Guidelines are the standard of care for injured workers. Additional information about the Medical TreatmentGuidelines, including e-learning training, is available on the Board's website.9.HIPAA NOTICE - In order to adjudicate a workers' compensation claim, WCL 247 13-a(4)(a) and 12 NYCRR 247 325-1.3 require healthcare providers to regularly file medical reports of treatment with the Board and the insurer or employer. Pursuant to 45 CFR 247164.512these legally required medical reports ar