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The goal of workers' comp is for injured workers to return to a productive life. You play an important role in delivering the care needed to make that possible.
As your office provides care, follow these four steps:
Treat emergencies immediately or prepare to ask a few discovery questions if the situation is not urgent. Find out if the injury is work-related by asking:
If the patient indicates that it was work related, ask if their employer has workers’ compensation coverage or use the Texas Department of Insurance coverage verification tool.
While it's up to insurance carriers to determine if claims are work-related, proceed with caring for the injured worker as a workers’ compensation patient as long as the patient indicates the injury happened at work and the employer has workers’ compensation coverage.
Many of our policyholders choose to participate in the WorkWell, TX network - Texas Mutual’s own health care network. If the patient’s employer is covered by Texas Mutual, call us at (888) 532-5246 or contact the employer to determine if they participate in the network.
Your role is to provide appropriate return-to-work focused care for injured employees. Some treatment requires pre-authorization, which you can read about below or discuss with us by calling (888) 532-5246.
If an injured employee's employer is covered by Texas Mutual, they can get their first prescription filled even if their employer hasn't filed a claim yet. Provide the injured employee with a First Fill form (English PDF, Spanish PDF) to use at a participating Optum pharmacy.
Texas law requires health care providers to submit their bills to insurance carriers electronically unless they have fewer than 10 employees and workers’ compensation represents less than 10% of their business.
Bills for Texas Mutual should be submitted to Jopari Solutions (payer ID: 22945). For more information, contact Jopari Solutions at (866) 269-0554.
Carriers have 45 days to review and process your complete bill. After 30 days, you can check on the status of your Texas Mutual bill online or by calling (888) 532-5246.
The Texas Department of Insurance, Division of Workers' Compensation created DWC Form-73 to help health care providers communicate injured workers' restrictions and physical abilities to employers and insurance carriers.
This helps ensure that appropriate return-to-work programs are implemented. The form also helps the insurance carrier investigate and process the claim.
The DWC Form-73 is required:
DWC rules allow you to charge up to $15.00 each time you complete DWC Form-73. For more information on Form DWC-73 filing and reimbursement requirements, see Rule 129.5.
We partner with Optum to help injured workers get the prescriptions they need for compensable on-the-job injuries. If you need assistance from Optum, call (888) 220-2805.
If you prescribe medication for the treatment of injured workers, be familiar with the Texas Department of Insurance pharmacy regulations.
Our First Fill program allows injured workers to receive a seven-day supply of their medication before their employer files a claim.
Texas law requires most health care providers to submit their bills to insurance carriers electronically. Bills for Texas Mutual should be submitted to Jopari Solutions (payer ID: 22945). For more information, contact Jopari Solutions at (866) 269-0554.
Texas Mutual reviews bills to ensure that they were submitted timely and accurately, and that treatment and services were necessary and related to the compensable injury. After we take final action on your bill, we will generate an explanation of benefits.
CMS-1500 for all physician services and ambulatory surgical services (using the instructions on the DWC-67)
UB-04 for all facility charges, including hospital, inpatient and outpatient services, and home health services (using the instructions on the DWC-68)
DWC-66 for all pharmacy services (this form includes the proper instructions)
Use the links below to access Texas Department of Insurance, Division of Workers' Compensation (DWC) forms.
Claims and billing
Pharmacy benefit manager
Our quarterly WorkWell, TX newsletter provides you with the latest news, resources and insights to help you do business with us and better serve your workers' compensation patients. See our October 2021 edition.