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You are here: Home . wc . news . advisories . ad2001-14

Advisory 2001-14

Clarification for the Transition to Amended 134.600 Concerning Preauthorization, Concurrent Review and Voluntary Certification of Health Care, Effective January 1, 2002.

The Texas Workers' Compensation Commission (Commission) provides clarification for the transition from the preauthorization requirements effective prior to January 1, 2002, to the amended requirements for preauthorization effective beginning January 1, 2002. The clarification applies to:

  1. Those treatment(s) and service(s) that are initiated on or before December 31, 2001 and that will continue on or after January 1, 2002; and
  2. those recommendations for spinal surgery that are received on or before December 31, 2001 for surgeries to be performed on or after January 1, 2002.

This advisory specifically addresses and clarifies the following situations:

Situation I - Inpatient hospital admissions including principal procedure and length of stay:
Prior to January 1, 2002, preauthorization is required for non-emergency inpatient hospitalizations, but is not required for the principal procedure or the length of stay. On or after January 1, 2002, amended 134.600 requires preauthorization for non-emergency inpatient hospital admissions including the principal procedure and the length of stay.

Preauthorization requested on or before December 31, 2001 will be governed by the rule in effect on the date the preauthorization request was submitted to the carrier. No additional preauthorization for either the procedure or the length of stay will be required if the preauthorization request was submitted on or before December 31, 2001 and subsequently approved. Preauthorization requests submitted on or after January 1, 2002, must comply with the Commission's amendments to 134.600 effective January 1, 2002.

Situation II - Spinal Surgery:
Prior to January 1, 2002, recommendations for spinal surgery are governed by 133.206, Spinal Surgery Second Opinion Process. Effective January 1, 2002, non-emergency spinal surgery requires preauthorization under amended 134.600.

Pursuant to 133.206, the Commission will accept recommendations for spinal surgery (TWCC-63 forms) until 5:00 P.M. CST on December 31, 2001. For recommendations received on or before December 31, 2001, a second opinion concurrence or carrier waiver will allow surgery to be performed without preauthorization on or after January 1, 2002, and within the timeframes established by 133.206.

Pursuant to amended 134.600, requests for preauthorization submitted on or after January 1, 2002, must be preauthorized by the insurance carrier prior to performing non-emergency spinal surgery.

Situation III - Work Hardening, Work Conditioning Programs, & Rehabilitation Programs:
Prior to January 1, 2002, only work hardening and work conditioning programs in excess of six and four weeks respectively require preauthorization. Amended 134.600 provides an exemption from preauthorization and concurrent review for work hardening or work conditioning programs, if provided by a facility that is both accredited by the Commission on the Accreditation of Rehabilitation Facilities ( CARF) for work hardening (CARF-Comprehensive Occupational Rehabilitation) or work conditioning (CARF-General Occupational Rehabilitation) and exempted by the Commission. Work hardening and work conditioning programs require preauthorization if the facility is not accredited by CARF and not exempted by the Commission.

Prior to January 1, 2002, services by pain clinics require preauthorization. Amended 134.600 requires preauthorization and concurrent review for rehabilitation programs, to include outpatient medical rehabilitation and chronic pain management/interdisciplinary pain rehabilitation.

A work hardening or work conditioning program or an outpatient medical rehabilitation or chronic pain management/interdisciplinary pain rehabilitation program for an injured employee initiated before January 1, 2002, will require preauthorization for continuation of the program past January 31, 2002, unless the program is exempted by the Commission. Preauthorization requested on or before December 31, 2001 for such a program will be subject to the rule in effect at the time the request was submitted. However, preauthorization is required for any above-referenced program initiated on or after January 1, 2002, unless exempted by the Commission in accordance with 134.600 (h)(9) and Advisory 2001-11.

Programs exempted by the Commission will be posted under "What's New?" on the TWCC web site, www.tdi.texas.gov .

Signed this 28 th day of December, 2001

Richard F. Reynolds, Executive Director

Distribution:
TWCC Staff
Medical Professional Associations
Carrier Representatives
Forms Notification List
Public Information List
TWCC web site



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