The New Preauthorization Rule

Saturday, July 1, 2006 | 0

On April 10, 2006, Workers' Compensation Commissioner Albert Betts adopted amendments to Rule 134.600, the Division of Workers' Compensation (DWC) rule regarding preauthorization, concurrent review, and voluntary certification of health care. The adopted rule replaces the emergency rule adopted by Commissioner Betts on November 3, 2005 and published in the November 18, 2005 issue of the Texas Register (30 TexReg 7624). The emergency rule was subsequently extended and the extension was published in the March 10, 2006 issue of the Texas Register (31 TexReg 1539). The amendments to the rule are necessary to implement provisions of House Bill (HB) 7 that was passed by the Texas Legislature during the 79th Legislature's regular session in 2005.

The new rule became effective May 2, 2006.

HB 7 made changes Section 413.014 of the Texas Labor Code and requires that the DWC's preauthorization and concurrent review rule include revisions that require health care providers to seek preauthorization and concurrent review for certain treatments including physical and occupational therapy. The reform legislation also created a new Section 408.0042(d) which requires health care providers to seek preauthorization of treatments for any injury or diagnosis not accepted as compensable by the insurer following an examination by the treating doctor.

The new rule does not apply to networks certified under Chapter 1305 of the Texas Insurance Code or political subdivisions with contractual relationships provided for by Section 504.053(b)(2) of the Texas Labor Code.

The new rule addresses several statutory requirements by incorporating several provisions of the Texas Labor Code:

* Section 408.028, regarding pharmaceutical closed formularies; and

* Section 413.011, regarding treatment guidelines, protocols, and treatment plans.

Subsection (p) of the rule lists 14 categories of health care treatment and services that require preauthorization. Subsection (q) lists the health care requiring concurrent review for an extension for previously approved services.

New Rule 134.600 and the associated rule adoption preamble can be found on the DWC's website at: http://www.tdi.state.tx.us/wc/rules/adopted/documents/1346aorder0406.pdf.

List of Health Care Requiring Preauthorization:

Pre-Emergency Rule List Valid through Nov. 1 2005
* Inpatient hospital admissions including the principal schedule procedure(s) and the length of stay
* Outpatient surgical or ambulatory surgical services
* Spinal surgery as required by Sec. 408.026 of the Texas Labor Code
* All psychological testing and psychotherapy, repeat interviews, and biofeedback; except when any service is part of a preauthorized or exempt rehabilitation program
* All external and implantable bone growth stimulators
* All chemonucleolysis
* All myelograms, discograms, or surface electromyograms
* Unless otherwise specified, repeat individual diagnostic study with fee in current MFG of greater than $350 or documentation of procedure (DOP) required
* Work hardening and work condition-ing services provided in a facility that has not been approved for exemption by the DWC
* Rehabilitation programs to include outpatient medical rehabilitation, chronic pain management, and inter-disciplinary pain rehabilitation
* All durable medical equipment (DME) that costs in excess of $500 per item (purchase and cumulative rental) and transcutaneous electrical nerve stimulators (TENS) units
* Nursing home, convalescent, residential, and all home health care services and treatments
* Chemical dependency or weight loss programs
* 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
List of Health Care Requiring Concurrent Review:
* Inpatient length of stay
* Work hardening or work conditioning services
* Investigational or experimental services or use of devises
* Rehabilitation programs
* DME in excess of $500 per item and TENS usage
* Nursing home, convalescent, residential, and home health care services
* Chemical dependency or weight loss programs

Emergency Rule List Effective Nov. 2, 2005 -
* Inpatient hospital admissions including the principal schedule procedure(s) and the length of stay
* Outpatient surgical or ambulatory surgical services
* Spinal surgery as required by Sec. 408.026 of the Texas Labor Code
* All psychological testing and psychotherapy, repeat interviews, and biofeedback; except when any service is part of a preauthorized or exempt rehabilitation program
* All external and implantable bone growth stimulators
* All chemonucleolysis
* All myelograms, discograms, or surface electromyograms
* Unless otherwise specified, repeat individual diagnostic study with fee in current MFG of greater than $350 or documentation of procedure (DOP) required
* Work hardening and work conditioning services provided in a facility that has not been approved for exemption by the DWC
* Rehabilitation programs to include outpatient medical rehabilitation, chronic pain management, and inter-disciplinary pain rehabilitation
* All durable medical equipment (DME) that costs in excess of $500 per item (purchase and cumulative rental) and transcutaneous electrical nerve stimulators (TENS) units
* Nursing home, convalescent, residential, and all home health care services and treatments
* Chemical dependency or weight loss programs
* 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
* Physical and occupational therapy services rendered on or after Dec. 1, 2005
List of Health Care Requiring Concurrent Review:
* Inpatient length of stay
* Work hardening or work conditioning services
* Investigational or experimental services or use of devises
* Rehabilitation programs
* DME in excess of $500 per item and TENS usage
* Nursing home, convalescent, residential, and home health care services
* Chemical dependency or weight loss programs
* Physical and occupational therapy services

Adopted Permanent Preauth. Rule List Effective May 2, 2006 -
* Inpatient hospital admissions including the principal schedule procedure(s) and the length of stay
* Outpatient surgical or ambulatory surgical services
* Spinal surgery
* All psychological testing and psychotherapy, repeat interviews, and biofeedback; except when any service is part of a preauthorized or DWC exempt rehabilitation program
* Unless otherwise specified in this subsection, a repeat individual diagnostic study with a reimburse-ment rate of greater than $350 as established in the current MFG or without a reimbursement rate established in the current MFG
* All non-exempted work hardening or non-exempted work conditioning programs
* Chronic pain management, and inter-disciplinary pain rehabilitation
* All durable medical equipment (DME) that costs in excess of $500 per item (purchase and cumulative rental)
* 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
* Physical and occupational therapy services
* Drugs not included in the DWC's formulary
* Treatments and services that exceed or are not addressed by the DWC's adopted treatment guidelines or protocols and are not contained in a treatment plan authorized by the insurance carrier
* Any treatment for an injury or diagnosis that is not accepted by the carrier pursuant to Section 408.0042 and Rule 126.14 (relating to Treating Doctor Examination to Define the Compensable Injury)
List of Health Care Requiring Concurrent Review:
* Inpatient length of stay * All non-exempted work hardening or non-exempted work conditioning programs
* Investigational or experimental services or use of devises
* Chronic pain management/inter-disciplinary pain rehabilitation
* Physical and occupational therapy services
* Required treatment plans

===============Footnotes===============

1 The proposed rules clarifies that the preauthorization process applies to specific non-emergency health care.

2 A comprehensive occupational rehabilitation program or a general occupational rehabilitation program constitutes work hardening or working conditioning, respectively, for purposes of the Pre-Emergency Rule. All work hardening and work conditioning programs that was initiated on or after Jan. 1, 2004 and prior to March 15, 2004 was subject to preauthorization and concurrent review.

3 Services listed in the Healthcare Common Procedure Coding System (HCPCS), Level I, ode range for Physical Medicine and Rehabilitation, but limited to: modalities (both supervised and constant attendance), therapeutic procedures (excluding work hardening and work conditioning), and other procedures limited to the unlisted physical medicine and rehabilitation procedure code.

4 Preauthorization is not required for the first two 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 approved by the insurance carrier.

5 Services listed in HCPCS 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 and other procedures limited to the unlisted physical medicine and rehabilitation procedure code, Level II temporary codes for physical and occupational services provided in a home setting. Preauthorization is not required 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 insurance carrier.

6 Includes those services listed in the Healthcare Common Procedure Coding System (HCPCS) 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 and other procedures limited to the unlisted physical medicine and rehabilitation procedure code, Level II temporary codes for physical and occupational services provided in a home setting. Preauthorization is not required 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 insurance carrier.

Article republished with the permission of the Insurance Council of Texas. www.insurancecouncil.org

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