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. However, 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 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 listed 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
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.
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.
daisyBill Solution
Stay up-to-date on the latest developments in workers’ comp medical billing by subscribing to daisyNews.