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ADVISORY 2003-13

SUBJECT: Coordination of ADL, Preauthorization, and MFG (CMS payment policies)

The Texas Workers' Compensation Commission (Commission) provides clarification regarding Centers for Medicare and Medicaid Services (CMS) payment policies, and the Approved Doctor List with respect to Commission Rules 134.600 (Preauthorization, Concurrent Review, and Voluntary Certification of Health Care), and 134.202 (Medical Fee Guideline).

The Commission has adopted CMS payment policies in 134.202, Medical Fee Guideline (MFG); however, subsection (a)(4) of this rule provides: "Specific provisions contained in the Texas Workers' Compensation Act (the Act), or Texas Workers' Compensation Commission (Commission) rules, including this rule, shall take precedence over any conflicting provision adopted by or utilized by CMS in administering the Medicare program." In the workers' compensation system injured employees are entitled to all necessary and reasonable medical treatment to cure or relieve the effects of the compensable injury.

For reimbursement, health care treatments and services listed in subsection (h) of 134.600 must be preauthorized in the Texas Workers' Compensation Commission system. Carriers should not process a preauthorization request if the requesting doctor is not on the Commission's Approved Doctor List (ADL) and has not been granted by the Commission a temporary exception to the requirement to be on the ADL. Those doctors are not entitled to provide or be reimbursed for health care services in the workers' compensation system. Carriers should notify the requestor the request is not being processed due to the doctor not being on the ADL and not having the temporary exception, by whatever methods it currently employs to communicate with the requestor. A carrier may wish to inform the doctor of the Commission's online process for application to the ADL.

When processing preauthorization requests, the carrier is required by rule 134.600(f)(1) to "...approve or deny requests for preauthorization or concurrent review based solely upon the reasonable and necessary medical health care required to treat the injury..." Medical necessity is the over-riding factor for workers' compensation cases and must be established on a case-by-case basis. Since the Commission has adopted CMS payment policies for reimbursement of medical treatments and services, CMS medical necessity payment policies should be a component of the carrier's preauthorization screening criteria, but shall not be the sole factor in determining medical necessity.

In applying CMS payment policies to the retrospective review of medical bills, carriers must determine whether the CMS policy addresses medical necessity in the particular case being considered. If the carrier denies payment based upon the lack of medical necessity, the carrier must use the initial denial code "U." If there are any CMS payment policies that would also lead to the denial, code "Y" should also be used.

Carriers should retrospectively deny payment for medical bills submitted by doctors not on the Commission's ADL, or doctors that have not been granted by the Commission a temporary exception to the requirement to be on the ADL, except in an emergency as defined in 133.1 of this title (relating to Definitions for Chapter 133) or for immediate post-injury medical care, as defined in 180.1 (relating to Definitions), in accordance with 180.20, Commission Approved Doctor List, subsection (a).

Signed on this 1st day of August, 2003

Richard F. Reynolds, Executive Director

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