Preauthorization and treatment guidelines

Non-network

• Workers' compensation non-network preauthorization educational materials:
  • Step 1, determine if a non-network health care service requires preauthorization.
  • Step 2, the steps to request non-network preauthorization. 
• Workers’ compensation applicable laws and rules addressing non-network preauthorization and treatment guidelines are:
  • Texas Labor Code Section 413.014 Preauthorization Requirements; Concurrent Review and Certification of Health Care.
  • 28 Texas Administrative Code (TAC) Section 134.600 Preauthorization, Concurrent Utilization Review, and Voluntary Certification of Health Care
  • 28 TAC 134.530 Requirements for Use of the Closed Formulary for Claims Not Subject to Certified Networks
  • Non-network treatment guidelines, Official Disability Guidelines (ODG) | Disability management

Network

• Workers' compensation network preauthorization educational materials:
  • Step 1, determine if a health care service requires preauthorization by checking your network contract.
  • Step 2, the steps to request network preauthorization.
• Workers’ compensation applicable laws and rules addressing network preauthorization and treatment guidelines are:
  • Texas Insurance Code, TIC Chapter 4201
  • TIC Chapter 1305
  • 28 TAC Chapter 10, Subchapter F Workers’ Compensation Network Utilization Review 
  • 28 TAC 134.540 Requirements for Use of the Closed Formulary for Claims Subject to Certified Networks
  • Check your network contract for the treatment guidelines, see information for network health care providers.

Utilization review agents

• Workers’ compensation applicable laws and rules for utilization review agents are:
  • Texas Insurance Code, TIC Chapter 4201
  • 28 TAC Chapter 19, Subchapter U Workers Compensation Utilization Review