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Preauthorization for workers' compensation claims is the process required whereby medical providers request approval to provide specific types of medical treatment before the treatment of service is provided. Rules and procedures for workers' compensation pre-authorization are developed by and overseen by the Texas Department of Insurance - Division of Workers' Compensation (DWC).
Each workers' compensation carrier in Texas is required to use a Utilization Review Agent licensed by the Texas Department of Insurance. For each preauthorization request, the preauthorization agent has 3 business days to make a determination by either approving or denying the request. Additional documentation may be needed to support the requested services before they can be approved. If the treatment is denied, the medical provider or injured worker has 30 days to appeal the decision.
The Pool uses Texas Association of School Board Risk Management Fund (TASBRMF) as it's Utilization Review Agent. The Pool and TASBRMF make up 85% of all claims in the Political Subdivision Workers' Compensation Alliance. This means that 85% of all preauthorization requests are being handled by the same process, giving consistency to the Alliance providers.
The Pool's Workers' Compensation Preauthorization Process Explained
The following is a summary of the types of treatment that require preauthorization, according to the DWC.
- Inpatient hospital admission
- Outpatient surgery or ambulatory surgery services
- Spinal surgery
- Work hardening or work conditioning
- Physical therapy and occupational therapy greater than six treatments
- Investigational or experimental services or devices
- Psychotherapy exceeding six visits
- Psychological testing exceeding three hours
- Repeat individual diagnostic study greater than $350
- Durable medical equipment over $500
- Chronic pain management/interdisciplinary pain rehabilitation
- Drugs, "N" drugs such as narcotics, opioids, investigational or experimental, intrathecal drug delivery systems such as pain pumps
- Treatments or procedures that fall outside the Official Disability Guidelines
It's important to note that emergency treatments do not require preauthorization.
I've been injured; help me understand the process. Here's an infographic that outlines what to do when you are injured at work.
The preauthorization process can, at times, be confusing for the member and for the injured employee. While most of the time the preauthorization process works very well, some of the regulations governing the process may actually create more confusion than if there were no regulations at all. For example, if three days isn't sufficient time for the preauthorization process to be completed - through no fault of the Pool, its member, or the inured employee - an administrative denial of the requested procedure has to be issued. If this happens, members should make sure they understand what is happening by talking to the Pool's claims adjuster assigned to the case in question. Most of these issues can be clarified and completed as long as the member, the claims adjuster and the injured employee remain in close communication.
If you have any questions about the preauthorization process, please contact the Pool's Workers' Compensation Claims Department, your claims adjuster or your member services manager. To see the list of health care services that require preauthorization, please download The Alliance - Appendix A.
The Texas Municipal League Intergovernmental Risk Pool is the leading provider of workers’ compensation, liability, and property coverage for local governments in Texas. Founded in 1974, we are the oldest and largest pool of its type in the United States, serving over 2800 governments and political subdivisions. We are driven to continue the mission that began over 40 years ago, providing our members with a tailored risk financing system through reliable partnership, performance, and service.
If you are currently looking for coverage, or have any questions please contact our team with any questions.
