What is the difference between an MG-2 and C-4AUTH request?
Many medical providers file requests for medical treatment authorization to ensure that the services rendered are paid for by the carrier. When the recommended treatment exceeds the Medical Treatment Guidelines or is not addressed within the Medical Treatment Guidelines, the medical providers are required to file a request for authorization of such services by way of an MG-2 form or C-4Auth form. If the medical provider does not file the treatment request on the proper form, the request can be denied due to its procedural defectiveness. This inadvertently saves the carrier costs by not having to obtain a contradictory medical opinion for the purposes of denying the request on the basis of medical necessity.
Treatment that falls within the Medical Treatment Guidelines for the back, neck, knees, shoulders and carpal tunnel syndrome are pre-authorized and do not need to be pre-approved by the carrier. The exception is if the provider is requesting one of the following 11 procedures: Lumbar Fusion, Artificial Disc Replacements, Vertebroplasty, Kyphoplasty, Electrical Bone Growth Stimulators, Spinal Cord Stimulators, Intrathecal Drug Delivery (Pain Pumps), Osteochondral Autograft, Autologous Chondrocyte Implantation, Meniscal Allograft Transplantation and Knee Arthroplasty (total or partial knee joint replacement) or second/subsequent performance of a surgical procedure because of a failure or incomplete success. If the provider wishes to proceed with any of these 11 procedures, a C-4AUTH request must be filed. A C-4AUTH form must also be filed if the recommended treatment cost exceeds $1,000.00
An MG-2 form is used when a provider recommends treatment that exceeds the Medical Treatment Guidelines or when the treatment is not addressed by the Guidelines. The provider must support the MG-2 request by specifying legitimate objective bases for the need to deviate from the Guidelines. We most commonly receive MG-2 requests from providers when the claimant needs extended physical therapy, multiple injections or chiropractic adjustments.
Lastly, if the C-4AUTH or MG-2 request is incorrectly completed or is not served properly on the carrier, the request should be denied. For more information on whether an MG-2 or C-4AUTH can be denied, please contact Usra Hussain at firstname.lastname@example.org.