Fillable PLEASE READ CAREFULLY THE FOLLOWING INFORMATION FOR DETERMINING (New York State)

Fill Online, Printable, Fillable, Blank PLEASE READ CAREFULLY THE FOLLOWING INFORMATION FOR DETERMINING (New York State) Form

Use Fill to complete blank online NEW YORK STATE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

PLEASE READ CAREFULLY THE FOLLOWING INFORMATION FOR DETERMINING (New York State)

On average this form takes 17 minutes to complete

The PLEASE READ CAREFULLY THE FOLLOWING INFORMATION FOR DETERMINING (New York State) form is 3 pages long and contains:

  • 0 signatures
  • 15 check-boxes
  • 59 other fields

Country of origin: US
File type: PDF

Free fillable forms for New York State

BROWSE NEW YORK STATE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
IMPORTANT:
PLEASE READ CAREFULLY THE FOLLOWING INFORMATION FOR DETERMINING HOW TO FIND
INSURER/SELF-INSURER CONTACTS
MG-2, ATTENDING DOCTOR'S REQUEST FOR APPROVAL OF VARIANCE AND INSURER'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-variance-request
MG-2.0 (4-18) COVER SHEET
Patient's Name:
I certify that I am making the above request for approval of a variance and my affirmative statements are true and correct. I certify that I have read and applied the
Medical Treatment Guidelines to the treatment and care in this case and that I am requesting this variance before rendering any medical care that varies from the
Guidelines. I certify that the patient understands and agrees to undergo the proposed medical care. I contact the insurer by telephone to discuss
this variance request before making the request. I contacted the insurer by telephone on and spoke to (person spoke to or was not able to
speak to anyone)
did /
(date)
did not
The undersigned requests approval to VARY from the WCB Medical Treatment Guidelines as indicated below:
ATTENDING DOCTOR'S REQUEST FOR APPROVAL OF
VARIANCE AND INSURER'S RESPONSE
For additional variance requests in this case, attach Form MG-2.1.
Answer all questions where information is known.
MG-2
MG-2.0 (4-18) Page 1 of 2
C.
WCB Case #: Claim Administrator Claim (carrier case) #: Date of Injury/Illness:
B.
A.
First MI Last
Date of service of supporting medical in WCB case file, if not attached:
Date(s) of previously denied variance request for substantially similar treatment, if applicable:
Employer's Name & Address:
Insurer's Name & Address:
Social Security No.:
Attending Doctor's Name & Address:
Approval Requested for: (one request type per form)
Patient's Address:
STATEMENT OF MEDICAL NECESSITY - See item 5 on instruction page.
Your explanation must provide the following information:
- the basis for your opinion that the medical care you propose is appropriate for the patient and is medically necessary at this time; and
- an explanation why alternatives set forth in the Medical Treatment Guidelines are not appropriate or sufficient.
Additionally, variance requests to extend treatment beyond recommended maximum duration/frequency must include:
- a description of the functional outcomes that, as of the date of the variance request, have continued to demonstrate objective improvement from that
treatment and are reasonably expected to further improve with additional treatment; and
- the specific duration or frequency of treatment for which a variance is requested.
Variance requests for treatment or testing that is not recommended or not addressed, must include:
- the signs and symptoms that have failed to improve with previous treatments provided according to the Medical Treatment Guidelines; and
- medical evidence in support of efficacy of the proposed treatment or testing- may include relevant medical literature published in recognized peer
reviewed journals.
I sent or directed my office to send a copy of this request to the insurer, the Chair, the patient and the patient's legal representative, if any, on the same day, and sent or
directed my office to send a copy to the Workers' Compensation Board within two (2) business days of the date below. In addition, I certify that I do not have a
substantially similar request pending and that this request contains additional supporting medical evidence if it is substantially similar to a prior denied request.
Provider's Signature:
Date:
Designated contact information not available.
(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. If the treatment requested is not addressed by the Guidelines, in the remaining boxes use NONE)
-
Guideline Reference:
Telephone No.: Fax No.:
NPI No.:
-
Individual Provider's WCB Authorization No.:
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:
C. I am not equipped to send or receive forms by fax or email. This form was mailed (return receipt requested) on:
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-variance-request. 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. If
you are unable to send or receive email or fax, complete C.
MG-2.0 4-18
I request that the Workers' Compensation Board review the insurer's denial of my doctor's request for approval to vary from the Medical
Treatment Guidelines. I opt for the decision to be made by the Medical Arbitrator designated by the Chair or through WCB adjudication. I
understand that if either party, the insurer or the claimant, opts in writing for resolution through adjudication, the case shall proceed for proposed
decision and, if not therein resolved, to a WCB hearing. I understand that if neither party opts for resolution by adjudication, the variance issue
will be decided by a medical arbitrator and the resolution is binding and not appealable under WCL § 23.
(Please complete if request is denied.) If the issue cannot be resolved informally, I opt for the decision to be made by the Medical Arbitrator
designated by the Chair or through WCB adjudication. I understand that if either party, the insurer or the patient, opts in writing for resolution
through adjudication, the case shall proceed for proposed decision and, if not therein resolved, to a WCB Hearing. I understand that if neither party
opts for resolution by adjudication, the variance issue will be decided by a medical arbitrator and the resolution is binding and not appealable under
WCL § 23.
Insurer's response to the variance request is indicated in the checkboxes on the right. Insurer
denial, when appropriate, should be reviewed by a health professional. (Attach written report of
medical professional.) If request is approved or denied, sign and date the form in Section E.
I certify that copies of this form were sent to the Treating Medical Provider requesting the variance, the Workers' Compensation Board, the claimant's
legal representative, if any, and any other parties of interest, with the written report of the medical professional in the office of the insurer/employer/
self-insured employer/Special Fund attached, within two (2) business days of the date below.
I certify that the provider's variance request initially denied above is now granted or partially granted.
MG-2.0 (4-18)
Page 2 of 2
DENIAL INFORMALLY DISCUSSED AND RESOLVED BETWEEN PROVIDER AND INSURER / EMPLOYER
INSURER'S / EMPLOYER'S RESPONSE TO VARIANCE REQUEST
CLAIMANT'S / CLAIMANT REPRESENTATIVE'S REQUEST FOR REVIEW OF INSURER'S / EMPLOYER'S DENIAL
E.
G.
F.
INSURER'S / EMPLOYER'S NOTICE OF INDEPENDENT MEDICAL EXAMINATION (IME) OR MEDICAL RECORDS REVIEW
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL
BE PRESENTED TO OR BY AN INSURER, OR SELF-INSURER, ANY INFORMATION CONTAINING ANY FALSE MATERIAL STATEMENT OR CONCEALS ANY MATERIAL FACT
SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT.
D.
The self-insurer/insurer hereby gives notice that it will have the patient examined by an Independent Medical Examiner or the claimant's medical
records reviewed by a Records Reviewer and submit Form IME-4 within 30 calendar days of the variance request.
INSURER'S / EMPLOYER'S RESPONSE
If service is denied or granted in part, explain in space provided.
Granted
Denied
Burden of Proof Not Met
Substantially Similar
Request Pending or Denied
Granted in Part
Without
Prejudice
Patient Name: WCB Case #: Date of Injury/Illness:
NOTE to Claimant's / Claimant Licensed Representative's: The claimant should only sign this section after the request is fully or partially denied.
This section should not be completed at the time of initial request.
Title:
By: (print name)
Signature:
Date:
Title:By: (print name)
Signature:
Date:
Title:By: (print name)
Insurer's Signature:
Date:
Date:
Claimant's / Claimant Representative's Signature:
Name of the Medical Professional who reviewed the denial, if applicable:
YOU MUST COMPLETE THIS SECTION IF YOU WANT THE BOARD TO REVIEW THE INSURER'S DENIAL OF THE PROVIDER'S VARIANCE REQUEST.
NYS Workers' Compensation Board
PO Box 5205
Binghamton, NY 13902-52055
Email Filing: wcbclaimsfiling@wcb.ny.gov
l
Customer Service: (877) 632-4996
l
Statewide Fax: (877) 533-0337
THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION
l
www.wcb.ny.gov
1. This form is used for a workers' compensation, volunteer firefighters' or volunteer ambulance workers' benefit case as follows:
To request approval to vary the treatment of the patient identified on this form from the relevant Medical Treatment Guidelines.
2. This form must be signed by the Treating Medical Provider and must contain his/her authorization number and code letters. Out-of-State medical
providers must enter their NPI number. 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.
3. Please ask your patient for his/her WCB case number and the claim administrator claim (carrier case) number and show these numbers on the form. In
addition, ask your patient if he/she has retained a representative. If represented, ask for the name and address of the representative.
4. This request must be served on the workers' compensation insurer, Special Fund, or self-insured employer's designated contact identified on the Board's
website: wcb.ny.gov/medical-treatment-guideline-variance-request
. Failure to submit the request to the designated contact identified on the
Board's website may result in your request being denied. It may be mailed, return receipt requested, if the certification is completed that the Treating
Medical Provider is not equipped to send and receive the form by one of the prescribed methods of the same day transmission. On the same day, a copy
must also be sent to the Board, the patient, and the patient's legal representative, if any.
5. A variance must be requested using this form. All questions on this form must be answered completely. The treating medical provider must prove that it
is appropriate and medically necessary to vary from the Board's Medical Treatment Guidelines in the treatment of this patient, and that patient agrees to
the proposed medical care. Failure to provide sufficient reasons why a variance is necessary may result in the denial of the variance or may delay its
approval. Your explanation must provide the following information:
- the basis for your opinion that the medical care you propose is appropriate for the patient and is medically necessary at this time; and
- an explanation why alternatives set forth in the Medical Treatment Guidelines are not appropriate or sufficient.
Additionally, variance requests to extend treatment beyond recommended maximum duration/frequency must include:
- a description of the functional outcomes that, as of the date of the variance request, have continued to demonstrate objective improvement from
that treatment and are reasonably expected to further improve with additional treatment; and
- the specific duration or frequency of treatment for which a variance is requested.
Variance requests for treatment or testing that is not recommended or not addressed, must include:
- the signs and symptoms that have failed to improve with previous treatments provided according to the Medical Treatment Guidelines; and
- medical evidence in support of efficacy of the proposed treatment or testing - may include relevant medical literature published in recognized peer
reviewed journals.
No variance will be permitted for patients who exceed the 10 visit annual maximum for on-going maintenance care.
6. A supporting medical report must be submitted with this request if such report is not already in the Board's case file. No action will be taken on cases
without a supporting medical report. A medical report supporting the denial of the variance request is not necessary when the denial is based upon the
allegation that (1) the provider did not meet the burden of proof that a variance is appropriate, (2) the medical care for which the variance is requested has
already been rendered, (3) the medical care requested is not covered under Section 13(a) of the Workers' Compensation Law, (4) the patient did not
appear for a scheduled independent medical examination. or (5) a new variance request was submitted prior to a substantially similar being granted or
denied or a prior identical variance request has been denied, and the resubmitted request does not contain any additional documentation or justification.
7. If approval or denial is not forthcoming within 15 calendar days after the insurer has received the request and an IME or Medical Record Review is not
required, the variance is deemed approved and the Board will issue an Order of the Chair stating the request is approved. If the insurer decides either an
IME or records review is required, the insurer must notify the Board and Treating Medical Provider within 5 business days that it will be obtaining an
outside opinion. The insurer has 30 calendar days to get the IME exam or Medical Records Review and submit Form IME-4. If no notice of an IME or
Medical Record Review is submitted, the insurer has 15 calendar days from the date of the request to reply to the variance request.
8. If the claim is controverted, the Treating Medical Provider must request approval for the variance from the insurer or Special Fund who would be
responsible if the claim is established using this form and process.
9. If the insurer has checked "GRANTED" or "GRANTED IN PART" AND "WITHOUT PREJUDICE" in Section E, the liability for this claim has not yet been
determined. This authorization is made pending final determination by the Board. Pursuant to 12 NYCRR § 324.3(b)(4), this authorization is limited to the
question of medical necessity only and is not an admission that the condition for which the services are required is compensable. This authorization does
not represent an acceptance of this claim by the insurer, self-insured employer, employer or Special Fund or guarantee payment for the services
authorized. When a decision is rendered regarding liability, you will receive a Notice of Decision by mail. The insurer, self-insured employer, employer or
Special Fund will only provide payment for these services if the claim is established and the insurer, self-insured employer, employer or Special Fund is
found to be responsible for the claim.
10. If the insurer has checked "SUBSTANTIALLY SIMILAR REQUEST PENDING OR DENIED" in Section E, the denial is not subject to an Order of the Chair.
A substantially similar variance request may not be submitted unless the insurer has denied a previous request. Substantially similar requests that were
previously denied may be submitted with additional documentation or justification.
11. 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 (800) 781-2362.
12. The Medical Treatment Guidelines are the standard of care for injured workers.
13. HIPAA NOTICE - In order to adjudicate a workers' compensation claim, WCL § 13-a(4)(a) and 12 NYCRR § 325-1.3 require health care providers to
regularly file medical reports of treatment with the Board and the insurer or employer. Pursuant to 45 CFR § 164.512 these legally required medical
reports are exempt from HIPAA's restrictions on disclosure of health information.
TO THE PROVIDER - REQUEST FOR APPROVAL TO VARY FROM MEDICAL TREATMENT GUIDELINES
MG-2.0 (4-18)
TO THE INSURER/EMPLOYER/SELF-INSURED EMPLOYER/SPECIAL FUND
Response Time and Notification Required:
The insurer/employer/self-insured employer/Special Fund must approve or grant each variance request in writing by
completing this form and sending it by fax or email to the Treating Medical Provider, claimant's legal counsel, if any, any
parties of interest, and the Workers' Compensation Board. The insurer/ employer/self-insured employer/Special Fund may
respond orally to the Treating Medical Provider about the variance requested by such provider. If the insurer or Special Fund
initially respond orally, it still must send a written response within the appropriate time period. If the insurer submits a notice of
an IME or Medical Records Review within 5 business days of the variance request, the insurer has 30 calendar days to get
the IME exam or Medical Records Review and submit Form IME-4. If no notice of an IME or Medical Record Review is
submitted, the insurer has 15 calendar days from the date of the request to reply to the variance request.
Denial of the Variance Request:
For a denial of a variance request for medical treatment, the insurer/employer/self-insured employer/Special Fund must
explain why it was denied and attach the written report of the medical professional--a physician, registered physician
assistant, registered professional nurse, or nurse practitioner licensed by New York State, or the appropriate state where the
professional practices, who is employed by an insurer or Special Fund, or has been directly retained by the insurer or Special
Fund or is employed by a URAC accredited company retained by the insurer or Special Fund through a contract to review
claims and advise the insurer or Special Fund -- that reviewed the variance request. Such report shall include a list describing
the medical records reviewed by the medical professional when considering the variance request. The insurer has the option
to submit citations or copies of relevant literature published in recognized, peer-reviewed medical journals in support of a
denial of a variance request. A medical report supporting the denial of the variance request is not necessary when the denial
is based upon the allegation that (1) the provider did not meet the burden of proof that a variance is appropriate, (2) the
medical care for which the variance is requested has already been rendered, (3) the medical care requested is not covered
under Section 13(a) of the Workers' Compensation Law, (4) the claimant did not appear for a scheduled independent medical
examination, or (5) a new variance request was submitted prior to a substantially similar request being granted or denied or a
substantially similar variance request has been denied, and the resubmitted request does not contain any additional
documentation or justification.
Controverted Claims:
If the compensation case is controverted, the insurer/self-insured employer/employer/Special Fund must still respond to the
variance request timely and in the same manner as requests in non-controverted claims. If the insurer/employer/self-insured
employer/Special Fund approves a variance request when a claim is controverted or the compensability of the body part is
controverted, the approval only relates to medical necessity and shall not be construed as an admission that the condition for
which variance is requested is compensable. The insurer/employer/self-insured employer/Special Fund shall not be
responsible for the payment of medical care which is the subject of the variance request until the question of compensability
is resolved.
Failure to Timely Respond to Variance Report:
A valid variance may be deemed approved by an Order of the Chair issued by the Workers' Compensation Board if the
insurer/employer/self-insured employer/Special Fund fails to respond to a properly completed request within the time
frames specified above. The Order of the Chair is the final decision of the Board.
MG-2.0 (4-18)
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

PLEASE READ CAREFULLY THE FOLLOWING INFORMATION FOR DETERMINING (New York State)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 22 September 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document