Fill in a Valid C 4 Auth Template

The C 4 Auth form, also known as the Attending Doctor's Request for Authorization, is essential for obtaining written approval for special services that cost over $1,000 in workers' compensation cases. This form ensures proper communication between medical providers and insurers, streamlining the authorization process to facilitate necessary treatment for injured workers. To take the next step, complete the form by clicking the button below.

Jump Links

The C-4 Auth form plays a crucial role in the process of obtaining authorization for special medical services under Workers' Compensation law in New York State. This form caters to healthcare providers seeking compensation for services over $1,000 or services that require prior approval according to the established Medical Treatment Guidelines. It asks for essential information such as the patient's details, the attending physician's credentials, and the necessary treatment descriptions. To ensure a smooth process, it is imperative for providers to include the appropriate insurer or self-insurer contact information, which can be found on the Workers' Compensation Board's website. Additionally, the form includes a section where healthcare professionals must articulate the medical necessity of the requested services, and it specifies that timely submissions are critical, as delays may lead to automatic authorizations. Understanding the proper use of the C-4 Auth form is fundamental for medical professionals who want to navigate the authorization process effectively and ensure that their patients receive the treatments they need without unnecessary complications.

C 4 Auth Example

IMPORTANT:

PLEASE READ CAREFULLY THE FOLLOWING INFORMATION FOR DETERMINING HOW TO FIND INSURER/SELF-INSURER CONTACTS

C-4 AUTH, ATTENDING DOCTOR'S REQUEST FOR AUTHORIZATION 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/attending-doctors-request-authorization

C-4 AUTH (9-19) COVER SHEET

	ATTENDING DOCTOR'S REQUEST FOR	C-4
	AUTHORIZATION AND INSURER'S RESPONSE
		AUTH
	Answer all questions fully on this report

WCB Case #:

Claim Administrator Claim (Carrier Case) #:	Date of Injury/Illness:

A. Patient's Name:

Address:

Social Security No.:

First

Last

	Number and Street	City	State	Zip Code
Employer Name:

Address:

	Number and Street	City	State	Zip Code
Insurer Name:

Address:

	Number and Street	City	State	Zip Code
B. Attending Doctor's Name:

Address:

Number and Street

Individual Provider's WCB Authorization No.:

Telephone No.:

City

Fax No.:

State

Zip Code

NPI No.:

C. AUTHORIZATION REQUEST

The undersigned requests written authorization for the following special service(s) costing over $1,000 or requiring pre-authorization pursuant to the Medical Treatment Guidelines. Do NOT use this form for injuries/illnesses involving the Mid and Low Back, Neck, Knee, Shoulder, Carpal Tunnel Syndrome and Non-Acute Pain, except for the treatment/procedures listed below under Medical Treatment Guideline Procedures Requiring Pre-Authorization. Please use the appropriate Medical Treatment Guideline form if any other procedure/test is being requested.

Authorization Requested:

Diagnostic Tests:

Radiology Services (X-Rays, CT Scans, MRI) indicate body part:

Other

Therapy (including Post Operative):
Physical Therapy:	times per week for	weeks

Occupational Therapy:	times per week for	weeks

Other

Surgery:

Type of Surgery (Describe, include use of hardware/surgical implants)

Treatment:

Insurer Response: if any service

is denied, explain on reverse.

Granted	Granted w/o Prejudice	Denied
Granted	Granted w/o Prejudice	Denied
Granted	Granted w/o Prejudice	Denied
Granted	Granted w/o Prejudice	Denied
Granted	Granted w/o Prejudice	Denied
Granted	Granted w/o Prejudice	Denied
Granted	Granted w/o Prejudice	Denied

		Other					Granted		Granted w/o Prejudice	Denied
Medical Treatment Guidelines Procedures Requiring Pre-Authorization				(Complete Guideline Reference for each item checked, if necessary. 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.)

1.	Lumbar Fusions			B		-		E		4		a								.............................................................................															1.
1.	Lumbar Fusions			B		-		E		4		a																							1.

2. Artificial Disk Replacement												-		E														...........................................................							2.

3.	Vertebroplasty		B		-		E		7		a			i				................................................................................																	3.

4. Kyphoplasty		B		-	E			7		a			i		....................................................................................																				4.

5.	Electrical Bone Growth Stimulators																		-			E						a		...............................................					5.

6.	Osteochondral Autograft								K	-		D		1						f						................................................................									6.

7. Autologous Chondrocyte Implantation																K						D		1				f			.............................................				7.

8. Meniscal Allograft Transplantation														K		-					D									.................................................					8.

9. Knee Arthroplasty (total or partial knee joint replacement)																													K		-		F	2		............9.

10. Spinal Cord Stimulators								P		-		G		1											.................................................................										10.

11. Intrathecal Drug Delivery (pain pumps)																			P			-	G				2					.........................................			11.
12. Second or Subsequent Procedure
12. Second or Subsequent Procedure																	-												................................................						12.

C-4AUTH (9-19) Page 1 of 2

Granted

Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice

Denied

STATEMENT OF MEDICAL NECESSITY

Pursuant to 12 NYCRR 325-1.4(a)(1), it is the treating provider's burden to set forth the medical necessity of the special services required. Failure to do so may delay the authorization process. Your explanation of medical necessity must provide the basis for your opinion that the medical care you propose is appropriate for the patient and is medically necessary at this time.

Date of service of supporting medical in WCB Case File:

(Attach if not already submitted.)

Pursuant to 12 NYCRR 325.1(a)(3), the treating provider shall submit this form to the Workers' Compensation Board and insurer.

Providers must complete Part A below indicating that the request was sent to the insurer/self-insurer's designated fax or email address (see Board's URL address below*), unless the provider is not equipped to send or receive email or fax (complete "C" below). If the request was also sent to an additional fax or email address provided by the insurer, complete Part B below.

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:

If you called the insurer and spoke with an individual, provide the date of the call: and name of person contacted:

*Insurer/self-insurer's designated contact information is available online at: wcb.ny.gov/attending-doctors-request-authorization

Designated contact information not available.

I certify I am making the above request for certification. This request was made to the insurance carrier/self-insurer on: A copy of this form was sent to the Board on the date below.

Provider's Signature:

Date:

SELF-INSURED EMPLOYER / INSURER RESPONSE TO AUTHORIZATION REQUEST

Response Time and Notification Required:

The self-insured employer/insurer must respond to the authorization request orally and in writing via email, fax or regular mail with confirmation of delivery within 30 days. The 30 day time period for response begins to run from the completion date of this form if emailed or faxed, or the completion date plus five days if sent via regular mail. The written response shall be on a copy of this form completed by the treating provider seeking authorization and shall clearly state whether the authorization has been granted, granted without prejudice, or denied. Authorization can only be granted without prejudice when the compensation case is controverted or the body part has not yet been accepted(with or without prejudice). Authorization without prejudice shall not be construed as an admission that the condition for which these services are required is compensable or the employer/insurer is liable. The employer/insurer shall not be responsible for the payment of such services until the question of compensability and liability is resolved. Written response must be sent to the treating provider, claimant (patient), claimant's legal counsel, if any, the Workers' Compensation Board and any other parties of interest.

Denial of the Request for Authorization of a Special Service: A denial of authorization of a special service must be based upon and accompanied by a conflicting second opinion rendered by a physician authorized to conduct IMEs, or record review, or qualified medical professional, or a physician authorized to treat workers' compensation claimants. (If authorization is denied in a controverted case, the conflicting second opinion must address medical necessity only.) Failure to file timely the conflicting second opinion will render the denial defective. If denial of an authorization is based upon claimant's failure to attend an IME examination scheduled within the 30 day authorization period, contemporaneous supporting evidence of claimant's failure must be attached.

Failure to Timely Respond to Form C-4 AUTH: The special service(s) for which authorization has been requested will be deemed authorized by Order of the Chair if the self-insured employer/insurer fails to respond within 30 days (35 days if C-4AUTH is mailed with return receipt requested). An Order of the Chair is not subject to an appeal under Section 23 of the Workers' Compensation Law.

REASON FOR DENIAL(S), IF ANY. (ATTACH OR REFERENCE CONFLICTING SECOND MEDICAL OPINION AS EXPLAINED ABOVE.)

Date of service of supporting medical in WCB case file:

I certify that the self-insured employer/insurer telephoned the office of the health care provider listed above within the response time-frame indicated above and advised that the self-insured employer/insurer had either granted or denied approval for the special services for which authorization was sought, as indicated above, on the date below:

and

I certify that copies of this form were emailed, faxed, or mailed to the treating provider, the claimant (patient), the claimant's legal representative, if any, the Workers' Compensation Board and all parties of interest on the date below:

By: (print name)			Title:
Signature:					Date:

C-4AUTH (9-19) Page 2 of 2

www.wcb.ny.gov

REQUEST FOR WRITTEN AUTHORIZATION

IMPORTANT TO ATTENDING DOCTOR

AUTHORIZATION FOR SPECIAL SERVICES IS NOT REQUIRED IN AN EMERGENCY

1.This form is used for a workers' compensation, volunteer firefighters' or volunteer ambulance workers' benefit case to request written authorization for special service(s) costing over $1,000 in a non-emergency situation or requiring pre-authorization pursuant to the Medical Treatment Guidelines.

2.This form must be signed by the attending doctor and must contain her/his 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 # and the claim administrator claim (carrier case) number and show these numbers on this form. In addition, ask your patient if he/she has retained a representative. If represented, ask for the name and address of the representative.

This request must be sent to the Workers' Compensation Board, and the the workers' compensation insurance carrier, self-insured employer, or Special Fund. If patient is not represented, a copy must be sent to the patient.

4.The attending doctor must submit this form with the Board and on the same day serve a copy on the self-insured employer or the insurer by one of the following methods of service: a) the insurer's designated fax number, b) the insurer's designated email address, or c) by regular mail with confirmation of delivery. The insurer's designated fax and email address can be found at: wcb.ny.gov/attending-doctors-request-authorization. Failure to submit the request to the designated contact identified on the WCB's website may result in your request being denied. If there is no designated contact listed on the WCB website, check the "Designated contact information not available" box which is located at the bottom of Section C of this form.

5.If authorization or denial is not forthcoming within 30 calendar days, (or 35 days if C-4AUTH is mailed return receipt requested), the treatment is deemed authorized and the attending physician may provide the requested treatment.

6.SPECIAL SERVICES - Services for which authorization must be requested are as follows:

Physicians - To engage the services of a specialist, consultant, or a surgeon, or to provide for X-ray examinations or physiotherapeutic or other procedures, or to provide for special diagnostic laboratory tests costing more than $1,000.

Podiatrists - In treating the foot, to provide physiotherapeutic procedures, X-ray examinations, or special diagnostic laboratory tests costing more than $1,000. Chiropractors - In treating a condition as provided in Section 6551 of the Education Law, to engage the services of a specialist, consultant, or a surgeon, or to provide for X-ray examinations or physiotherapeutic or other procedures, or to provide for special diagnostic laboratory tests costing more than $1,000.

Occupational/Physical Therapists - In treating a condition as provided in Article 136 or 156 of the Education Law, in the Workers' Compensation Law, and the Rules of the Chair relative to Occupational/Physical Therapy Practice to provide occupational/physical therapy procedures costing more than $1,000.

Psychologists - Prior authorization for procedures enumerated in section 13-a(5) of the Workers' Compensation Law costing more than $1,000 must be requested from the self-insured employer or insurer. In addition, authorization must be requested for any biofeedback treatments, regardless of the cost, or and special diagnostic laboratory tests which may be performed by psychologists. Where a patient has been referred by an authorized physician to a psychologist for evaluation purposes only and not for treatment, prior authorization must be requested if the cost of consultation exceeds $1,000.

Medical Treatment Guidelines - Lumbar Fusions, Artificial Disk Replacement, Vertebroplasty, Kyphoplasty, Electrical Bone Growth Stimulators, Spinal Cord Stimulators, Osteochondral Autograft, Autologus Chondrocyte Implantation, Meniscal Allograft Transplantation, Knee Arthroplasty (total or partial knee joint replacement), Intrathecal Drug Delivery (pain pumps).

7.If the insurer has checked "GRANTED WITHOUT PREJUDICE" in Section C, the liability for this claim has not yet been determined. This authorization is made pending final determination by the Board. Pursuant to 12 NYCRR § 325-1.4(b)(2), 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.

8.It is the attending doctor's burden to set forth the medical necessity of the special services required. Be sure to provide this information in the Statement of Medical Necessity section of this form.

9.HIPAA NOTICE - In order to adjudicate a workers' compensation claim, WCL13-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.

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.

This form must be served on the insurer/self-insurer's designated contact identified on the Board's website:

www.wcb.ny.gov by fax, email or mailed, return receipt requested. Failure to submit the form to the designated contact identified on the Board's website may result in your request being denied. A copy of the form must also be filed with the Board.

NYS Workers' Compensation Board

PO Box 5205

Binghamton, NY 13902-5205

Email Filing: [email protected] l	Customer Service: (877) 632-4996 l Statewide Fax: (877) 533-0337
C-4AUTH (9-19)	THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION

Click for C 4 Auth File

File Breakdown

Fact Name	Description
Purpose	The C-4 AUTH form is used in workers' compensation cases to request authorization for medical services that exceed $1,000 or require pre-authorization under established Medical Treatment Guidelines.
Attending Doctor's Signature	The form must be signed by the attending doctor, who is responsible for providing the necessary medical necessity and authorization number.
Submission Methods	Requests can be submitted via fax, email, or regular mail. The designated contact information for insurers is available online.
Response Time	Insurers must respond to the authorization request within 30 days, or 35 days if sent by regular mail with a return receipt requested.
Special Services	Services requiring authorization include consultations, diagnostic testing, physical therapy, and surgery, among others. Only those above the $1,000 threshold must be requested.
GRANTED WITHOUT PREJUDICE	If granted without prejudice, it indicates that the liability for the case has not been determined and does not admit compensability.
Medical Treatment Guidelines	The form is applicable to various treatments specified in the Medical Treatment Guidelines, such as lumbar fusions and spinal cord stimulators.
C-4 AUTH Form Version	The version of the form used is C-4 AUTH (9-19), which refers to its last revision date of September 2019.
Filing Requirement	A copy of the completed form must be filed with the Workers' Compensation Board to remain compliant with regulations.
Legal Notification	Providers must be aware of their obligations under HIPAA and WCL regarding the disclosure of health information in relation to workers’ compensation claims.

Guide to Using C 4 Auth

Once you are ready to fill out the C-4 Auth form, it's essential to gather all necessary information and ensure accuracy. Each section needs to be completed with the correct details to facilitate the authorization process. Follow these steps carefully to complete the form.

Start by entering the WCB Case Number and the Claim Administrator Claim Number.
Provide the Date of Injury or Illness.
Fill in the patient's information:
- Patient's Name (First, MI, Last)
- Address (Number and Street, City, State, Zip Code)
- Social Security Number
Provide the employer's information:
- Employer Name
- Address (Number and Street, City, State, Zip Code)
Enter the insurer's information:
- Insurer Name
- Address (Number and Street, City, State, Zip Code)
Fill in the attending doctor's information:
- Doctor's Name
- Address (Number and Street, City, State, Zip Code)
- Individual Provider's WCB Authorization Number
- Telephone Number
- Fax Number
- NPI Number
Specify the authorization request by checking the appropriate services that cost over $1,000 or require pre-authorization, providing details for each category.
If applicable, provide explanations for any authorizations denied in the Insurer Response section on the reverse side of the form.
Complete the Statement of Medical Necessity section by providing a clear justification for the requested services.
Indicate the insurer's designated fax number or email address, along with any additional contacts, if necessary.
If you are not using fax or email, state that the form was mailed and provide the date.
Finally, complete the signature section, ensuring to sign and date the form appropriately.

After filling out the form, it must be submitted to the proper parties. This includes sending a copy to the Workers' Compensation Board and the insurer. Always ensure to follow the submission methods required to avoid any processing delays. Check the appropriate channels to confirm any additional requirements that may apply.

Get Answers on C 4 Auth

What is the purpose of the C-4 Auth form?

The C-4 Auth form is used to request written authorization for special medical services costing over $1,000 in a workers' compensation case. This form is necessary in non-emergency situations to ensure that the proposed treatment conforms to the Medical Treatment Guidelines. It also allows insurers and self-insurers to evaluate the medical necessity of the requested services.

Who needs to complete the C-4 Auth form?

The form must be completed by the attending physician who is proposing the medical services. This includes any licensed provider who is treating a workers' compensation claimant for injuries or illnesses that require costly or pre-authorized treatments. Out-of-state providers must also include their NPI number on the form.

What information is required on the C-4 Auth form?

Essential details include:

Patient's personal information such as name, address, and Social Security number.
Employer’s details, including name and address.
Insurer's information, including their name and designated contact method.
Specific requests for medical services, including types of treatments and associated costs.

Additionally, the attending doctor must provide their name, contact information, and WCB Authorization number. The form must also include a Statement of Medical Necessity explaining why the requested services are necessary for the patient's recovery.

How is the C-4 Auth form submitted?

The completed form should be submitted to the insurer or self-insured employer through one of the following methods:

Fax to the designated contact number listed on the Workers' Compensation Board's website.
Email to the designated email address.
Regular mail with a return receipt requested.

If the designated contact information is not available, the provider must check the appropriate box on the form. A copy of the form should also be sent to the Workers' Compensation Board.

What happens if the insurer does not respond to the C-4 Auth form?

If the self-insured employer or insurer fails to respond within 30 calendar days (or 35 days if mailed with a return receipt requested), the requested services are automatically authorized. This means the attending physician can proceed with the treatment without waiting for formal approval.

What does "Granted Without Prejudice" mean?

"Granted Without Prejudice" indicates that the insurer has approved the request temporarily, but this does not imply that they accept liability for the claim. The authorization is contingent upon further assessment and will not be considered an admission of the condition's compensability.

What if a service request is denied?

If the insurer denies the request for authorization, they must provide a conflicting second medical opinion or other evidence to support their decision. This documentation must accompany the denial letter. Failure to provide this information may render the denial invalid.

What is the significance of the Statement of Medical Necessity?

The Statement of Medical Necessity is a critical part of the C-4 Auth form. The attending physician must articulate why the proposed services are essential for the patient's treatment. Insufficient or vague explanations may lead to delays in obtaining authorization.

Where can I find the insurer's designated contact information?

Insurer or self-insurer designated contact information is available online at the Workers' Compensation Board's official website at wcb.ny.gov/attending-doctors-request-authorization . This information should be verified before submitting the C-4 Auth form to avoid potential complications.

Common mistakes

When filling out the C-4 Auth form, many individuals make common mistakes that can lead to delays in the authorization process. One major error is failing to provide complete and accurate patient information. This includes the patient's name, social security number, and address. If these fields are left incomplete, the insurer may not be able to process the request, leading to unnecessary holdups. Always double-check the personal details before submission.

Another frequent mistake involves incorrectly entering the insurer's designated contact information. It's crucial to obtain the correct name, fax number, or email address for the insurer as listed on the Workers' Compensation Board's website. If the information is wrong, the authorization request may never reach the appropriate party, resulting in a denial.

Additionally, many people forget to include a detailed statement of medical necessity. The attending physician must clearly explain why the requested services are necessary. Without this explanation, the insurer may find it difficult to justify approval, which can delay treatment for the patient. Be sure to take the time to articulate the medical reasoning behind the request.

Lastly, some submitters neglect to confirm their submission method. Whether the request was faxed, emailed, or mailed, it's important to document this information accurately on the form. Failure to indicate the submission method can lead to confusion about whether the request was timely submitted. Always specify how the C-4 Auth was sent and keep a record of it for future reference.

Documents used along the form

When dealing with the C-4 Auth form, several other forms and documents may be necessary to ensure a smooth authorization process for medical services in a workers' compensation case. Here are some common forms used alongside the C-4 Auth form:

C-4 Form: This is the initial claimant's report for workers' compensation. It provides basic details about the injury, including medical treatment and return to work status.
EWCB-1 (Employee's Claim for Workers' Compensation): An employee fills out this form to initiate a claim for benefits after an injury or illness related to work.
Form C-3 (Employer's Report of Work-Related Injury/Illness): This document details the employer's perspective on the incident and is used to report work-related injuries to the Workers' Compensation Board.
Form C-4.3 (Doctor's Report of Employee's Injury): A physician completes this report to give a detailed account of the diagnosis, treatment plan, and recovery time for the injured worker.
Form C-86 (Request for Reimbursement): This form is used by providers to seek payment for medical services rendered for a claim. It includes a breakdown of expenses related to the treatment.
Form 829 (Confirmation of Coverage): This verifies that the employer has appropriate workers' compensation coverage at the time of the employee's injury.
WCB-7 (Employee's Medical Report): Required to be filled by the treating physician and it certifies the medical necessity of treatment and any work restrictions.
Form C-7 (Notice of Decision): Issued by the Workers' Compensation Board, this document informs all parties involved about the decision on a claim request or appeal.
IMR-1 (Independent Medical Review): This request is filed when there is a disagreement on the medical necessity between the insurer and the treating provider, and an independent review is needed.

Each of these documents plays a key role in the workflow surrounding workers' compensation cases. Coordinating these forms effectively can help facilitate timely approvals and treatment for injured workers.

Similar forms

Form C-3: This form is similar as it is used to report an injured worker's injury or illness to the Workers' Compensation Board. Like the C-4 AUTH, the C-3 form details necessary information about the patient and the circumstances of the injury.
Form C-2: The C-2 form is also a report filed by employers about disability claims from their employees. It provides information on the injury and the employer's responses, mirroring the C-4 AUTH's need for detailed reporting.
Form C-8: This form is submitted to request a change in an injured worker's benefits. Both forms necessitate specific information about medical conditions and treatments to facilitate communication between all parties involved.
Form C-7: The C-7 form is used to report any changes in a claimant’s status, including return to work. Similar to the C-4 AUTH, it helps keep the insurer informed of the claim’s developments.
Form HCFA 1500: This medical claim form is used by healthcare providers to bill for services. Like the C-4 AUTH, it requires detailed information about the patient and the services rendered to ensure proper authorization and payment.
Form UB-04: Often used by hospitals and facilities to bill for services, the UB-04 resembles the C-4 AUTH in requiring comprehensive details related to treatment and billing practices.
Form C-9: The C-9 form is a request for reimbursement for medical expenses. It relates closely to the C-4 AUTH as both necessitate an explanation of medical necessity and costs involved.
Form ADA: The Americans with Disabilities Act form assesses a person's eligibility for accommodations. Similar to the C-4 AUTH, it requires medical documentation and justification for accommodations requested.
Form WCB-150: This form is used to report medical treatment details to the Workers' Compensation Board. Like the C-4 AUTH, it emphasizes efficiency in communication between medical professionals and insurers.

Dos and Don'ts

Things to Do When Filling Out the C-4 Auth Form:

Provide accurate and complete information throughout the form.
Ensure the form is signed by the attending doctor, including their authorization number.
Attach any necessary supporting medical documents, ensuring they are clearly labeled.
Submit the form directly to the insurer's designated contact as listed on the Workers' Compensation Board's website.

Things Not to Do When Filling Out the C-4 Auth Form:

Do not leave any required fields blank; incomplete forms may be rejected.
Avoid using this form for conditions that do not require pre-authorization.
Do not forget to include the WCB case number and claim administrator claim number.
Never send the form to an incorrect email or fax number, as this could delay processing.

Misconceptions

Misconception 1: The C-4 Auth form is only for emergency situations.

This form is specifically designed for non-emergency requests for services that cost over $1,000 or that require pre-authorization according to the Medical Treatment Guidelines. In emergencies, authorization is not required.

Misconception 2: Any medical provider can sign the C-4 Auth form.

The form must be signed by the attending doctor, who is responsible for the treatment. In some cases, if a patient is hospitalized, a member of the hospital's attending staff may sign it.

Misconception 3: The authorization request does not need to specify the treatment being sought.

It is crucial to clearly identify the special services being requested in the form. Including details about the specific treatments helps ensure that the request is processed correctly.

Misconception 4: Sending the form once is sufficient for authorization.

The form must be sent to both the Workers' Compensation Board and the insurer or self-insured employer. Multiple copies may be required based on the patient’s representation status.

Misconception 5: Insurers will always respond within the 30-day window.

While insurers are required to respond within 30 days, if they fail to do so, the treatment is automatically deemed authorized by Order of the Chair. This can vary based on how the form is submitted.

Misconception 6: If authorization is granted, the claim is automatically accepted.

Authorization without prejudice means the decision about liability is still pending. Just because services are authorized does not guarantee that the insurer accepts responsibility for the claim.

Key takeaways

Filling out and using the C-4 Auth form requires careful attention to detail and adherence to specific instructions. Here are key takeaways to keep in mind:

Purpose of the Form: The C-4 Auth form is utilized to request written authorization for special services exceeding $1,000 or those requiring pre-authorization according to the Medical Treatment Guidelines.
Documentation Requirement: Complete all sections of the form thoroughly. Provide essential details including the patient's name, injury details, and the attending doctor's information.
Submission Method: The form must be sent via the insurer/self-insurer's designated fax number, email address, or regular mail with confirmation of delivery.
Response Timeline: Insurers are obligated to respond within 30 days, or 35 days if the form was mailed. A lack of response within this timeframe results in automatic authorization of the requested treatment.
Medical Necessity Statement: Clearly explain the medical necessity for the requested services. This is crucial, as failure to provide adequate justification may delay authorization.
Emergency Situations: For emergencies, the authorization for special services is not required on the C-4 Auth form.
Potential Denials: If a service is denied, the insurer must provide a conflicting second opinion to substantiate the denial. This is mandatory to ensure the legitimacy of the decision.
Implications of Denial: A denial does not negate responsibility for payment if the claim is found compensable later. However, services granted without prejudice cannot be interpreted as an acceptance of liability.