Preauthorization

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.

Fax preauth request forms to (800) 852-1805.

To check the status of a preauth request or find out whether a procedure requires preauth, call (888) 532-5246.

In-Network Preauthorization

The following services require preauthorization if treatment is being provided for an in-network claim (effective 6/1/2009):

  • All non-emergency hospital or ASC (inpatient, outpatient, and observation) admissions including principle scheduled procedures and length of stay. Preauthorization request should include specific hardware, implantables, external delivery system, etc. to be utilized.
  • All non-emergency surgeries represented by AMA CPT codes 10010-69990 and/or G codes which represent a surgical procedure performed in a setting or place of service other than the doctor’s office [POS 11]. Preauthorization request should include specific hardware, implantables, external delivery system, etc. to be utilized.
  • All Botox Injections
  • All spinal Injections (including but not limited to):
    • Epidural Steroid Injection
    • RFTC or Cryotherapy/Cryoablation
    • Sacral Iliac Joint Injection
    • Facet Injection
    • Medial Branch Block
  • Trigger Point Injections (represented by AMA CPT 20553)
  • Bone Growth Stimulators
  • Discograms
  • Implantable Drug Delivery System
  • Investigational or experimental procedures or devices as determined by ODG or listed as an AMA Category III Code.
  • Stimulator Devices (including, but not limited to):
    • TENS Units
    • Interferential Units
    • Neuromuscular Stimulators
    • Dual Units
    • Spinal Cord Stimulator
    • Peripheral Nerve Stimulator
    • Brain Stimulator
  • Cumulative Chiropractic Treatments (including manipulations and office visits) greater than 14 visits and/or greater than 10 weeks from date of injury.
  • Manipulations under Anesthesia (MUA)
  • Cumulative Physical Therapy/Occupational Therapy greater than 14 visits and/or greater than 10 weeks from date of injury.
  • Biofeedback
  • All Initial and Repeat MRI and CT Scans
  • Bone Density Scans
  • Unless otherwise specified in this list, all repeat individual diagnostic studies (series) having a billed amount greater than $350.
  • Surface Electromyography (EMG)
  • Durable Medical Equipment (DME), Prosthetics and/or Orthotics, greater than $500.00 billed (purchase or accumulated rental or combination of rental/purchase).
  • Gym Memberships
  • Alternative Treatment (including, but not limited to):
    • Acupuncture outside ODG
    • Acupressure
    • Yoga
  • Rehab Programs (including, but not limited to):
    • Work Conditioning
    • Work Hardening
    • Chronic Pain Management Program
    • Medical Rehabilitation
    • Brain and Spinal Cord Rehabilitation
    • Chemical Dependency Programs
    • Weight Loss Programs
  • Nursing Home (including, but not limited to):
    • Skilled nursing facility, including skilled care within the same facility.
    • Convalescent Care
    • Residential Care
    • Assisted Living
    • Group Homes
  • Psychological and/or Psychotherapy (including but not limited to):
    • Subsequent Evaluations
    • Subsequent Tests or Testing
    • All Therapy
    • All Biofeedback

Out-of-Network Preauthorization

Important Notice: The Texas Department of Insurance, Division of Workers' Compensation has adopted new disability management rules for non-network claims. Under these rules, treatments outside the adopted treatment guideline require preauthorization. Click here to read more about disability management. DWC Rule 137.100 provides specific information on the use of treatment guidelines.

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:

  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 Rule 134.600(a)
  3. spinal surgery
  4. all non-exempted work hardening or non-exempted work conditioning programs
  5. 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
  6. Level II temporary code(s) for physical and occupational therapy services provided in a home setting
  7. 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
  8. 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
  9. 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
  10. 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
  11. all durable medical equipment (DME) in excess of $500 billed charges per item (either purchase or expected cumulative rental)
  12. chronic pain management/interdisciplinary pain rehabilitation
  13. drugs not included in the Division's formulary
  14. 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
  15. required treatment plans
  16. 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)

Back to top

Out-of-Network Concurrent Review

The following health care services require concurrent review for an extension for previously approved services:

  1. inpatient length of stay
  2. all non-exempted work hardening or non-exempted work conditioning programs
  3. physical and occupational therapy services as referenced in Rule 134.600(p)
  4. investigational or experimental services or use of devices
  5. chronic pain management/interdisciplinary pain rehabilitation
  6. required treatment plans

Back to top

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:

  1. Compliance with the Division's fee guidelines;
  2. Compliance with the Division's treatment guidelines;
  3. Duplicate billing;
  4. Upcoding and/or unbundling;
  5. Billing for treatment(s) and/or service(s) unrelated to the compensable injury;
  6. 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;
  7. Accuracy of coding in relation to the medical record and reports;
  8. Correct calculations; and/or
  9. Provision of unnecessary and/or unreasonable treatment(s) and/or service(s).

Back to top