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• In-Network Preauthorization
• Out-of-Network Preauthorization
• Retrospective review
Important Notice: The Texas Department of Insurance, Division of Workers' Compensation has adopted new disability management rules for non-network claims effective May 1, 2007. Under these rules, treatments outside the adopted treatment guideline require preauthorization. Click here to read more about disability management.
To download a preauthorization request form, Click here. To expedite your request, download this form, complete it, and send it via email to preauth@texasmutual.com.
To request preauthorization by phone, call (888) 532-5246.
To fax your request, fax the preauth request form to (800) 852-1805.
In-Network Preauthorization
The following services require preauthorization if treatment is being provided for an in-network claim (effective 2/5/2007):
- All surgeries (CPT codes 1-6 and G codes which represent a surgical procedure) with a billed amount greater than $500.00. PreAuth Request should include specific hardware to be used for the procedure.
- Artificial Disc Surgery
- Intradiscal Electrothermal Annuloplasty (IDET)
- Chemonucleolysis
- Chiropractic treatments greater than 8 visits
- Bone Density Scans
- Myelograms
- Discograms
- Surface Electromyography (EMG)
- Durable medical equipment (DME) greater than $500.00 billed (purchase or accumulated rental or combination of rental/purchase)
- External and implantable bone growth stimulators
- Gym memberships
- Home health care visits/services
- Non-emergency inpatient hospital services including principle scheduled procedures and length of stay
- Chemical Dependency Programs
- Implantable drug delivery system
- Injections (Botox Injections, Epidural Steroid Injection, Facet Injection, Joint Steroid Injection, RFTC or cryotherapy/cryoblation of any nerve or joint, Sacral Iliac joint injection, Trigger Point Injections, Radiofrequency Thermocoagulation (RFTC) of facet joints)
- Investigational or Experimental procedures or devices including, but not limited to Prolotherapy, Sclerotherapy, Adhesiolysis to include neuroplasty, Racz neurolysis or percutaneous epidural neuroplasty, Standing MRI, Vax-D, Electrocorpeal Shock Wave Therapy (ESWT), Low Energy Electrocorpeal Shock Wave Therapy, Low level laser therapy (LLLT), Percutaneous electrical nerve stimulation (PENS), Peripheral neuromodulation therapy (PNT), Single photon emission computed tomography (SPECT)
- Manipulations under anesthesia
- Stimulator Devices including, but not limited to TENS units, Interferential units, Neuromuscular stimulators, Dual units, Spinal Cord Stimulator, Dorsal Column Stimulator, Peripheral nerve Stimulator, Brain Stimulator
- Nursing home: Skilled nursing facility, including skilled care within the same facility, Convalescent care, Residental care
- Orthotic Devices - billed amount more than $150.00
- Physical Therapy/Occupational Therapy Greater than 14 visits
- Acupuncture/Accupressure
- Psychological testing and Psychotherapy evaluations, testing, therapy and biofeedback
- Rehab Programs (including, but not limited to):
- Work Conditioning greater than 2 weeks
- Work Hardening greater than 2 weeks
- Chronic Pain Management Program
- Medical Rehabilitation
- Brain and Spinal Cord Rehabilitation
- Weight loss programs
Out-of-Network Preauthorization
All preauthorization requests for non-network services must be made in accordance with the Division of Workers'
Compensation (the Division) Rule 134.600, which states that health care providers must obtain preauthorization for:
- inpatient hospital admissions, including the principal scheduled procedure(s) and the length of stay
- outpatient surgical or ambulatory surgical services as defined in Rule 134.600(a)
- spinal surgery
- all non-exempted work hardening or non-exempted work conditioning programs
- physical and occupational therapy services, which includes those services listed in the Healthcare Common Procedure Coding System (HCPCS) at the following levels:
- Level I code range for Physical Medicine and Rehabilitation, but limited to:
- Modalities, both supervised and constant attendance
- Therapeutic procedures, excluding work hardening and work conditioning
- Orthotics/Prosthetics Management
- Other procedures, limited to the unlisted physical medicine and rehabilitation procedure code
- Level II temporary code(s) for physical and occupational therapy services provided in a home setting
- 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:
- the date of injury, or
- a surgical intervention previously preauthorized by the carrier
- 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
- all psychological testing and psychotherapy, repeat interviews, and biofeedback, except when any service is part of a preauthorized or Division exempted return-to-work rehabilitation program
- unless otherwise specified in this subsection, a repeat individual diagnostic study:
- with a reimbursement rate of greater than $350 as established in the current Medical Fee Guideline, or
- without a reimbursement rate established in the current Medical Fee Guideline
- all durable medical equipment (DME) in excess of $500 billed charges per item (either purchase or expected cumulative rental)
- chronic pain management/interdisciplinary pain rehabilitation
- drugs not included in the Division's formulary
- 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 carrier
- required treatment plans
- any treatment for an injury or diagnosis that is not accepted by the carrier pursuant to Labor Code §408.0042 and §126.14 of this title (relating to Treating Doctor Examination to Define the Compensable Injury)
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Out-of-Network Concurrent Review
The following health care services require concurrent review for an extension for previously approved services:
- inpatient length of stay
- all non-exempted work hardening or non-exempted work conditioning programs
- physical and occupational therapy services as referenced in Rule 134.600(p)
- investigational or experimental services or use of devices
- chronic pain management/interdisciplinary pain rehabilitation
- required treatment plans
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Out-of-Network Retrospective Review
All treatments or services that do NOT require preauthorization or concurrent review
are subject to retrospective review by the insurance carrier. Retrospective review
of a health care provider’s bill may include:
- Compliance with the Division's fee guidelines;
- Compliance with the Division's treatment guidelines;
- Duplicate billing;
- Upcoding and/or unbundling;
- Billing for treatment(s) and/or service(s) unrelated to the compensable injury;
- Billing for services not documented or substantiated, when documentation is required in accordance with the Division's fee guidelines or rules in effect for the dates of service;
- Accuracy of coding in relation to the medical record and reports;
- Correct calculations; and/or
- Provision of unnecessary and/or unreasonable treatment(s) and/or service(s).
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