When New York workers' compensation treatment or testing is not covered by any Medical Treatment Guideline and costs more than $1,000, the provider files a Non-MTG Over $1,000 PAR in OnBoard. It replaced Form C-4AUTH for these requests. The claim administrator has 30 calendar days to respond, and a denial goes to a priority hearing for adjudication rather than to the Medical Director's Office.
The Board-authorized treating provider makes the request, and delegates with their own Board-assigned user IDs can draft it for the provider's review. The claim administrator responds in OnBoard.
Download the current version from the source each time; forms change without notice.
Non-MTG Over $1,000 Prior Authorization Request (PAR)
New York State Workers' Compensation Board takes this form through its online services or your EMR, so there is no PDF to fill. Vero Scribe writes the visit note it draws on, so the details are ready when you complete it.
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The Non-MTG Over $1,000 PAR in OnBoard. Since May 2, 2022, treatment or tests costing over $1,000 for body parts or conditions without applicable Medical Treatment Guidelines are requested online, and paper C-4AUTH requests are no longer accepted.
Thirty calendar days. The due date shows on the OnBoard Active tab, and if the claim administrator does not respond within the timeframe, an Order of the Chair may be issued. Weekend or holiday deadlines may extend under General Construction Law 25-a.
Denials of Non-MTG Over $1,000 PARs go to a priority hearing, and disagreements are resolved through the Board's adjudication process. The Medical Director's Office Level 3 review used for guideline, DME and medication requests does not decide these.