FOR IMMEDIATE RELEASE TO THE TEXAS ORTHOPEDIC ASSOCATION E-CONNECT NEWSLETTER

Doctors who treat patients in the workers' compensation system are required to obtain preauthorization from the insurance carrier for certain health care treatment or services.  This article explains when preauthorization is required by statute or rule for non-network treatments and services. This article also addresses how to use the adopted treatment guidelines to determine when treatments or services, not listed in these guidelines require preauthorization. This article does not address health care provided in a certified network or out-of-network health care.

The Texas Labor Code, in §413.014, Preauthorization Requirements, Concurrent Review and Certification of Health Care, lists specific health care treatments and services that will require a doctor to seek preauthorization, and it also allows the Commissioner of Workers' Compensation to adopt rules that specify additional  health care treatments and services that require preauthorization.  The Commissioner adopted rules may be found in 28 Texas Administrative Code §134.600, Preauthorization, Concurrent Review and Voluntary Certification of Health Care.  The list below includes all non-network health care treatments or services specifically listed in the statute and rules that require preauthorization.

Medical Treatments or Services Requiring Preauthorization 

1. Spinal surgery.
2. Work hardening or work-conditioning services provided by a health care facility that is not credentialed by an organization and exempted from preauthorization in accordance with Commissioner rules.
3. Inpatient hospitalization, including principal scheduled procedures and length of stay.
4. Certain physical and occupational therapy (see the rule for more detail regarding physical therapy preauthorization requirements.)
5. Outpatient or ambulatory surgical services as defined in §134.600.
6. Any investigational or experimental services or devices as defined in §134.600.
7. All psychological testing and psychotherapy, repeat interviews, and biofeedback unless the service is part of a preauthorized or Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC) exempted return-to-work rehabilitation program.
8. Unless otherwise specified, a repeat individual diagnostic study, with a reimbursement established in the current Medical Fee Guideline of greater than $350 or without a reimbursement rate in the Medical Fee Guideline.
9. All durable medical equipment with billed charges greater than $500 per item (either purchase or expected cumulative rental.)
10. Chronic pain management/interdisciplinary pain rehabilitation.
11. Drugs not included in the TDI-DWC formulary.¹
12. Treatment and services that exceed or are not addressed by the Commissioner's adopted treatment guidelines or protocols and are not in a treatment plan preauthorized by the insurance carrier.
13. Required treatment plans.²
14. Any treatment for an injury or diagnosis that is not accepted by the insurance carrier following the treating doctor's examination to define the compensable injury.

¹The Commissioner of Workers' Compensation has not adopted a closed drug formulary at the time this article was published.

²Required treatment planning rules are not currently in effect.

Texas Labor Code §413.011 also requires the Commissioner of Workers' Compensation to adopt rules and treatment guidelines that are evidence-based, scientifically valid, and outcome-focused and that are designed to reduce excessive or inappropriate medical care while safeguarding necessary medical care for injured employees.  The result of this statutory provision was 28 Texas Administrative Code §137.100 Treatment Guidelines – the workers' compensation treatment guideline rules (applies to health care provided on or after May 1, 2007) – which include the Official Disability Guidelines (ODG) Treatment in Worker's Comp.

Doctors who wish to provide health care treatments or services that are not included in list above, should always consult the ODG.  Health care provided in accordance with the ODG and that is not included in the list above is presumed to be reasonably required for treatment of an injured employee and does not require preauthorization. However, doctors may seek voluntary preauthorization (voluntary certification) from the workers' compensation insurance carrier for these treatments and services if they choose (Texas Labor Code § 418.014).  In most instances, health care that exceeds the recommended treatments or services for diagnoses listed in the ODG, or medical care for diagnoses not listed in the ODG, does require preauthorization.

To obtain access to or copies of the ODG, contact the Work Loss Data Institute at www.worklossdata.com. Contact the TDI-DWC Comp Connection for Health Care Providers line at 512-804-4000 or toll-free at 800-372-7713 with questions relating to providing health care services in the Texas workers' compensation system.

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