There seems to be confusion among healthcare providers and their staff regarding which services must be preauthorized under Texas Worker’s Compensation rules, what is required of the provider, and what are the obligations of the carrier.
A number of treatments and services do require preauthorization, below are just a few:
- Inpatient hospital admissions
- Surgical procedures
- Physical and Occupational Therapy services
- Durable Medical Equipment with billed charges greater than $500 (this includes splints and other orthotics)
Today we will address the rules as they pertain to Physical and Occupational therapy services.
Preauthorization for these services is not required for the first six visits following an examination when the treatments are rendered within the first two weeks following the date of injury or a surgical intervention previously approved by the insurance carrier. However, it is important to note that all medical services that do not require preauthorization are subject to retrospective review for medical necessity by the carrier and reimbursement could be denied. Therefore, it would be prudent to submit a preauthorization request as soon as possible even if you find that your patient’s care falls within the 2 week “window”. If it has been more than 2 weeks since the date of injury or surgery, preauthorization of therapy services is required.
Steps in the preauthorization process:
- Verify the claim—make certain that the date of injury you were given is accurate, the claim number is accurate, and find out what that specific carrier’s preauthorization requirements are. What number should the request be faxed to? Does the carrier have a specific form that they require or can you use your own?
- Schedule the patient for an initial evaluation. Keep in mind that while many therapists choose to treat the patient on the same visit as the initial eval, if those treatment services were not preauthorized, there might be no compensation for the treatment other than the evaluation.
- Once the evaluation is completed and signed by both the therapist and the referring Dr. ( if the Dr. signature cannot be obtained quickly, a script from the referring Dr. will usually suffice) the preauthorization request may be submitted along with the evaluation/treatment plan and/or Dr’s script with all the pertinent patient information as well as diagnosis, frequency and duration and specific procedure codes being requested.
- The carrier must then approve or deny a request via phone, email, or fax within 3 working days.
Preauthorization Rule – 28 Texas Administrative Code §134.600
Preauthorization rules under the Texas Administrative Code can be found at http://tinyurl.com/lkxvsr. More information regarding Texas Worker’s Compensation requirements may be found at http://www.tdi.state.tx.us/wc/index.html.
CRT works with Texas Workers Compensation claims on a daily basis. If we can be of assistance, please feel free to contact us.