What is the difference between Pre-authorization and Optional Prior Approval?
A. Pre-authorization: For the four body parts covered by the Guidelines, pre-authorization is only required for procedures listed in the FAQ on pre-authorization. The pre-authorization process, used for treatments or procedures exceeding a $1,000 threshold, continues to be used for all other body parts. The pre-authorization process uses the C-4 AUTH form and it gives the carrier 30 days to respond to a request. During that period, the carrier has the right to obtain an IME or records review. To deny a pre-authorization request, the carrier must show a conflicting medical opinion. B. Optional Prior Approval: This process is streamlined and much more limited in focus, and is designed to only answer one question, “is the requested treatment or test a consistent application of the guidelines?” Providers are encouraged to submit the form (MG-1) electronically. Carriers have 8 business days to respond. Disputes are resolved by a binding decision of the Board’s Medical Director’s office. The
