MEDICAL TREATMENT GUIDELINES – HOW DO I GET TREATMENT ?

Treatment for injuries to the neck, back, knee, shoulder, and carpal tunnel syndrome are now covered under the Medical Treatment Guidelines. There are three options for your doctor in providing you with treatment. “Treatment” means diagnostic tests, medications, therapy, surgery, injections, etc.

1. If it is an emergency, then there is no prior authorization needed. The doctor does what is required, submits the bills and reports to the insurance company, and if they contest the issue of whether it was an emergency or whether the treatment was necessary or related to your case, they will object to the bill. In that event a Judge would decide the issue.

2. If it is not an emergency, then the doctor must read the Medical Treatment Guidelines and make a decision whether the requested treatment is covered and pre-approved on the Guidelines. If it is, then the doctor proceeds without authorization and sends bills and reports to the insurance company. Again, if the insurance company objects, then a Judge will decide the issue.

3. If the doctor concludes that the requested treatment is not covered or pre-authorized on the Guidelines, then the doctor must submit a request for a “variance” using form MG-2. The insurance company will grant or deny the variance. If there is a denial, then your doctor must discuss the denial with you and you must sign the MG-2 form to request a hearing so that a Judge can decide the issue.

Our office does not become involved in the process until there is a denial. In situations (1) and (2), the Board will either schedule a hearing or issue a Proposed Decision responding to the insurance company’s objection to the medical bill, and we will review the Proposed Decision or attend the hearing as indicated.

In situation (3), if we receive a copy of the variance denial (which does not always occur), we will review it. The Board will automatically deny a variance request that does not meet its requirements, which are that the doctor must show why you need treatment not covered by the Guidelines. If we feel that your doctor’s variance request is inadequate, we will write to your doctor to try to get a better request filed. If the variance request appears adequate, then we will execute it for you and file it, requesting a hearing or a decision by the Board’s Medical Director.

Obviously we cannot guarantee that the Board will decide in your favor on any particular medical dispute, and your chances of success depend largely on the quality of your medical reports and your doctor’s willingness to testify on your behalf.