Preauthorization is a prospective utilization review in which a provider requests an insurance carrier to authorize a proposed treatment before treating a compensable injury.
In Texas workers’ comp, not all treatments require preauthorization. Providers must obtain preauthorization before furnishing select services to treat injured workers.
Below, this article outlines preauthorization requirements for non-network and network claims.
Non-Network Preauthorization
Providers must obtain preauthorization before furnishing select treatments to injured workers with non-network claims.
If the insurance carrier approves the provider’s request, the provider may proceed with the requested treatment.
The provider may follow the appeal process if the insurance carrier issues an adverse determination denying the proposed treatment.
Providers may refer to the diagram below, which can be found on the DWC website.
Step 1: Determine if the Service Requires Preauthorization
Providers must determine whether the proposed service requires preauthorization before treating injured workers with non-network claims. However, providers do not need to request preauthorization before furnishing emergency care or services not included on the list below.
For non-network claims, providers must obtain preauthorization for the treatments listed below.
- Inpatient hospital admissions
- Outpatient or ambulatory surgery
- Spinal surgery
- Work conditioning or work hardening
- Physical or occupational therapy beyond six early visits
- Investigational or experimental services
- Psychological testing and psychotherapy
- Diagnostic studies over $350
- Durable medical equipment over $500 per item
- Chronic pain management programs
- Drugs not included in the Closed Formulary
- Treatments exceeding or outside the Official Disability Guidelines (ODG)
- Required treatment plans
Step 2: Request Preauthorization
To request preauthorization, providers must submit their request to the claims administrator using one of the following methods:
- Telephone
- Facsimile
- Electronic transmission
Claims administrators must respond within 3 working days of receiving the request. Failure to meet this deadline constitutes an administrative violation but does not automatically authorize the proposed service.
Once approved, preauthorization cannot be revoked.
Adverse Determinations & Appeals
Before denying a preauthorization request and issuing an adverse determination, the Utilization Review Agent (URA) must give the provider at least one working day to discuss the proposed treatment.
Once a decision is made, the claims administrator must issue a written notice of either preauthorization approval or an adverse determination.
If the claims administrator denies the preauthorization request and issues an adverse determination, the provider may appeal the decision.
The provider must request the appeal orally or in writing within 30 days of receiving the written adverse determination.
A Utilization Review Agent (URA) must approve or deny the appeal within 30 days of receiving the appeal request.
If the appeal is denied, providers may request an independent review from an Independent Review Organization (IRO).
To submit a request for independent review, providers must:
- Fill out an LHL009 form with the URA
- Submit the LHL009 within 45 days after receiving the URA’s denial of an appeal non-network.
Network Preauthorization
If the injured worker’s employer participates in a network, the injured worker must select a treating doctor from the network’s approved provider list.
Network providers must refer to the network contract for preauthorization requirements before treating injured workers with network claims.
Providers may refer to the diagram below, which can be found on the DWC website.
Step 1: Review the Network Contract
Providers must review their network contract to identify which services require preauthorization.
Additionally, providers must confirm the appropriate process and contact information for submitting preauthorization requests.
Step 2: Request Network Preauthorization
The method for submitting a preauthorization request depends on the network’s established procedures and requirements for submitting preauthorization requests.
Providers must verify whether requests can be submitted by telephone, facsimile, or electronic transmission.
When submitting preauthorization requests for network claims, providers must include all necessary medical documentation specified in their network contract.
Adverse Determinations & Appeals
A Utilization Review Agent (URA) must approve or issue an adverse determination within the following timeframes:
- Within the time appropriate to the delivery of services and the patient’s condition, not exceeding one hour of receiving a post-stabilization treatment or life-threatening condition request.
- Within 24 hours of receiving a concurrent hospitalization review request.
-
Within three working days of receiving all other preauthorization or concurrent review requests.
Before issuing an adverse determination, the URA must give the requester a reasonable opportunity to discuss the clinical basis of the adverse determination:
- No less than one working day before issuing an adverse determination.
- Before issuing a concurrent or post-stabilization review adverse determination.
The URA must send written notice of approval or adverse determination to the requester within one working day of the decision.
If the appeal is denied, network providers may request an independent review from an Independent Review Organization (IRO).
To submit a request for independent review, providers must:
- Fill out an LHL009 form with the URA
- Submit the LHL009 within 45 days after the denial date.
Texas |
Statute/Rule |
Statute |
|
Section |
413.014 - Preauthorization Requirements; Concurrent Review and Certification of Health Care |
Subsection Text |
(a) In this section, "investigational or experimental service or device" means a health care treatment, service, or device for which there is early, developing scientific or clinical evidence demonstrating the potential efficacy of the treatment, service, or device but that is not yet broadly accepted as the prevailing standard of care. (b) The commissioner by rule shall specify which health care treatments and services require express preauthorization or concurrent review by the insurance carrier. Treatments and services for a medical emergency do not require express preauthorization. (c) The commissioner's rules adopted under this section must provide that preauthorization and concurrent review are required at a minimum for: (1) spinal surgery, as provided by Section 408.026; (2) work-hardening or work-conditioning services; (3) inpatient hospitalization, including any procedure and length of stay; (4) physical and occupational therapy; (5) outpatient or ambulatory surgical services, as defined by commissioner rule; and (6) any investigational or experimental services or devices. (c-1) Notwithstanding Subsection (c)(2), the commissioner by rule may exempt from preauthorization and concurrent review work-hardening or work-conditioning services provided by a health care facility that is credentialed by an organization designated by commissioner rule. (d) The insurance carrier is not liable for those specified treatments and services requiring preauthorization unless preauthorization is sought by the claimant or health care provider and either obtained from the insurance carrier or ordered by the commissioner. (e) If a specified health care treatment or service is preauthorized as provided by this section, that treatment or service is not subject to retrospective review of the medical necessity of the treatment or service. (f) The division may not prohibit an insurance carrier and a health care provider from voluntarily discussing health care treatment and treatment plans and pharmaceutical services, either prospectively or concurrently, and may not prohibit an insurance carrier from certifying or agreeing to pay for health care consistent with those agreements. The insurance carrier is liable for health care treatment and treatment plans and pharmaceutical services that are voluntarily preauthorized and may not dispute the certified or agreed-on preauthorized health care treatment and treatment plans and pharmaceutical services at a later date. |
Rule |
28 Texas Administrative Code, Chapter 134 |
Section |
|
Subsection Text |
(p) Non-emergency health care requiring preauthorization includes: (1) inpatient hospital admissions, including the principal scheduled procedure(s) and the length of stay; (2) outpatient surgical or ambulatory surgical services as defined in subsection (a) of this section; (3) spinal surgery; (4) all work hardening or work conditioning services; (5) physical and occupational therapy services, which includes those services listed in the Healthcare Common Procedure Coding System (HCPCS) at the following levels: (A) Level I code range for Physical Medicine and Rehabilitation, but limited to: (i) Modalities, both supervised and constant attendance; (ii) Therapeutic procedures, excluding work hardening and work conditioning; (iii) Orthotics/Prosthetics Management; (iv) Other procedures, limited to the unlisted physical medicine and rehabilitation procedure code; and (B) Level II temporary code(s) for physical and occupational therapy services provided in a home setting; (C) except for the first six visits of physical or occupational therapy following the evaluation when such treatment is rendered within the first two weeks immediately following: (i) the date of injury; or (ii) a surgical intervention previously preauthorized by the insurance carrier; (6) any investigational or experimental service or device for which there is early, developing scientific or clinical evidence demonstrating the potential efficacy of the treatment, service, or device but that is not yet broadly accepted as the prevailing standard of care; (7) all psychological testing and psychotherapy, repeat interviews, and biofeedback, except when any service is part of a preauthorized return-to-work rehabilitation program; (8) unless otherwise specified in this subsection, a repeat individual diagnostic study; (A) with a reimbursement rate of greater than $350 as established in the current Medical Fee Guideline; or (B) without a reimbursement rate established in the current Medical Fee Guideline; (9) all durable medical equipment (DME) in excess of $500 billed charges per item (either purchase or expected cumulative rental); (10) chronic pain management/interdisciplinary pain rehabilitation; (11) drugs not included in the applicable division formulary; (12) treatments and services that exceed or are not addressed by the commissioner's adopted treatment guidelines or protocols and are not contained in a treatment plan preauthorized by the insurance carrier. This requirement does not apply to drugs prescribed for claims under §§134.506, 134.530 or 134.540 of this title (relating to Pharmaceutical Benefits); (13) required treatment plans; and (14) any treatment for an injury or diagnosis that is not accepted by the insurance carrier under Labor Code §408.0042 and §126.14 of this title (relating to Treating Doctor Examination to Define the Compensable Injury).
|
daisyBill Solution
Stay up-to-date on the latest developments in workers’ comp medical billing by subscribing to daisyNews.
SIGN UP FOR DAISYNEWS