• Increase Text Icon
  • Decrease Text Icon
  • Email Icon
  • Print this page
You are here: Home . wc . news . advisories . ad2003-12

ADVISORY 2003-12

SUBJECT: Reimbursements Involving Non-Approved Doctor List (ADL) Doctors

Beginning Sept. 1, 2003, the Texas Workers' Compensation Act and Commission Rule 180.20(a) require that a doctor be on the NEW Approved Doctor List (ADL) or granted a temporary exception to this requirement in order to provide treatment to an injured employee and receive payment. A doctor who is not on the ADL and has not been granted a temporary exception to the requirement to be on the ADL is a non-ADL doctor. There may be situations when a non-ADL doctor provides treatment to an injured employee and refers that employee to other health care providers, which includes both health care practitioners and health care facilities. This Advisory identifies those health care providers that should be paid for services and those health care providers that should not be paid for services in such a case.

The referring non-ADL doctor should not be paid for services provided while the doctor's status is non-ADL. If the non-ADL doctor refers the injured employee to a non-ADL referral or consulting doctor and the non-ADL referral or consulting doctor provides health care to the injured employee, the non-ADL referral or consulting doctor also should not be paid for said health care.

However, if a non-ADL doctor refers a patient to a referral or consulting doctor who is on the ADL or has been granted a temporary exception to the requirement to be on the ADL, the ADL referral/ consulting doctor should be paid for any reasonable and medically necessary health care provided.

Similarly, if a non-ADL doctor writes a reasonable and medically necessary prescription for the injured employee, the pharmacist should be paid for services. If a non-ADL doctor refers the injured employee to an ancillary provider (any provider that is not a doctor, e.g., physical therapists, psychologists, etc.) for reasonable and medically necessary health care, the ancillary provider should be paid for services. If a non-ADL doctor prescribes reasonable and necessary durable medical equipment (DME) to an injured employee, the DME provider should be paid for services.

If a non-ADL doctor refers the injured employee to a facility for reasonable and medically necessary care, the facility should be paid. However, any non-ADL doctor who treats the injured employee in the facility should not be paid for professional services.

Non-ADL doctors can be paid for reasonable and medically necessary emergency and immediate post-injury services.

Signed on this 25th day of July, 2003

Richard F. Reynolds, Executive Director

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



Contact Information and Other Helpful Links