Preauthorization Process and Access to Medical Dispute Resolution Addendum
Advisory 2001-03 issued February 22, 2001 addressed the processes for requesting and making decisions on preauthorization and requesting medical dispute resolution of a denial of preauthorization. That Advisory noted that if a carrier or its agent approves a request for preauthorization, the carrier is liable for the health care and may not retrospectively deny payment based on medical necessity, although the carrier is still permitted to retroactively dispute the amount of reimbursement.
The purpose of this addendum is to ensure that system participants understand that even if preauthorization is approved, the approval does not guarantee payment if there has been a final adjudication that the injury is not compensable or that the health care was provided for a condition unrelated to the compensable injury. "Final adjudication" means that the Commission has issued a final decision or order that is not longer appealable by either party.
Signed this 2nd day of April, 2001
Leonard W. Riley, Jr., Executive Director
Distribution:
TWCC Staff
Commission Representatives
Public Information List
Professional Medical Associations