Texas Department of Insurance Workers’ Compensation Health Care Networks (WCNs) Referrals and Preauthorization  Authority: Texas Insurance Code (TIC) Chapter 1305 and 28 TAC Chapter 10.  Required Notice: Employee notice of network requirements must include a list of services that require preauthorization and a statement that network must arrange for timely referrals to specialists. (28 TAC § § 10.60(g)(10) and 10.60(g)(15)).

Texas Department of Insurance Referrals by WCN Treating Doctors Treating Doctor Treating Doctor (e.g. HMO PCP, Family Doctor) Patient Specialist (Injured Worker) (e.g. Neurosurgeon)

Texas Department of Insurance Referral Procedures and Timeframe  Networks either approve or deny referral requests.  Timeframe: –“within the time frame appropriate under the circumstances” but, under any circumstances not later than seven days after the date the referral is requested. –(28 TAC §10.61(f)(3)(A))

Texas Department of Insurance Denial of a Referral Request  Employee options: appeal or file a complaint.  Networks may require complaints to be filed within 90 days of the denial. (TIC § (b) and 28 TAC §10.61(f)(3)(B)).  Network denials because the service is considered not medically necessary may be appealed to an independent review organization. (28 TAC §§10.61(f)(3)(C) and ).

Texas Department of Insurance What is “preauthorization”?  The process required to request approval from the insurance carrier or the network to provide a specific treatment or service before the treatment or service is provided. (TIC § (19) and 28 TAC §10.2(a)(22)).

Texas Department of Insurance Preauthorization List   Networks are required to adopt and periodically update a list of the services requiring preauthorization as part of their annual quality improvement work plan. (28 TAC §10.81(b)(2)(B)(iv)).

Texas Department of Insurance Preauthorization under WCNs:  The Labor Code preauthorization requirements are not applicable to WCNs.  WCNs and are not required to use preauthorization.  If WCNs and carriers use preauthorization, then they must comply with TIC § § and 28 TAC Chapter 10, Subchapter F apply. (TIC § (a)).  No preauthorization for emergencies.

Texas Department of Insurance Preauthorization Rules:  Provider contracts and subcontracts must include a statement that the network agrees to furnish to the provider, and the provider agrees to abide by, the list of any treatments and services that require preauthorization. (28 TAC §10.42(b)(8)).

Texas Department of Insurance What is an emergency?  Two types: medical and mental health  “Emergency” means either a medical or mental health emergency (TIC § (a)(7) and 28 TAC §10.2(a)(7)).

Texas Department of Insurance What is a “medical emergency”?  A sudden onset of a medical condition with acute (sufficiently severe) symptoms (severe pain) that without immediate medical attention could reasonably be expected to result in serious: (A) jeopardy to the patient’s health or bodily functions; or (B) dysfunction of any body organ or part. (TIC § (a)(13) and 28 TAC §10.2(a)(15)).

Texas Department of Insurance What is a “mental health emergency”?  A condition that could reasonably be expected to present danger to the person experiencing the mental health condition or another person. (TIC § (15) and 28 TAC §10.2(a)(17)).

Texas Department of Insurance Preauthorization Process  Carriers or utilization review (UR) agents receive preauthorization requests and transmit the determination indicating whether the proposed health care services are preauthorized.  Carriers or UR agents are required to respond to preauthorization requests within certain time periods. (28 TAC §10.102(d)).

Texas Department of Insurance Preauthorization Timeframes  If the proposed services are for concurrent hospitalization care, then the person performing utilization review must, within 24 hours of the receipt of the request, transmit a determination indicating whether the proposed services are preauthorized. (28 TAC §10.102(e)).

Texas Department of Insurance Preauthorization Timeframes  Post-stabilization treatment or a life- threatening condition requires a preauthorization determination “within the time appropriate to the circumstances relating to the delivery of services and the condition of the patient,” not to exceed one hour from receipt of the request. (28 TAC §10.102(f)).

Texas Department of Insurance Preauthorization Timeframes  For all other requests for preauthorization, the determination must be made no later than the third calendar day after the request is received. (28 TAC §10.102(g)).