CONFIRMATION OF MEDICAL BENEFITS COVERAGE
The Commission has been notified of incidents where insurance carriers have failed to confirm medical benefits coverage for treatment that does not require preauthorization under Rule 134.600. Particularly problematic is the situation when an insurance carrier informs a health care provider and/or a pharmacy that the insurance carrier will not pay for services because of a prospective dispute regarding the reasonableness or necessity of medical treatment. Other situations involve insurance carriers filing TWCC-21 forms disputing all future medical benefits for reasons other than the compensability of an injury. These actions should not occur and such situations will be considered by the Commission to be potential violations of the Texas Workers' Compensation Act.
If a health care provider or pharmacy contacts an insurance carrier before services are provided, and preauthorization is not required for the specific services, the insurance carrier must confirm whether or not coverage exists and should inform the requestor that preauthorization is not required. The confirmation of coverage can be accomplished by informing the requesting person that:
- the insurance carrier will pay for the reasonable and necessary medical treatment if it is related to the compensable injury, or
- a workers' compensation policy (was/was not) in effect for the date of injury.
Unless the specific service or treatment requires preauthorization under Rule 134.600, an insurance carrier shall not file prospective disputes on the reasonableness or necessity of the treatment being requested. Verification of coverage does not bind the carrier or limit the carrier's ability to retrospectively dispute the reasonableness or necessity of treatment after the carrier receives a bill for the services. An insurance carrier should inform a health care provider about a dispute, and the status of the dispute, when the insurance carrier has already filed a TWCC-21 with the Commission which disputes compensability (that an injury occurred in the course and scope of employment or that a particular problem is related to the compensable injury). Medical disputes for treatment already provided should be filed on the TWCC-62 form, Notice of Medical Payment Dispute, after the insurance carrier receives, audits, and adjusts the bills for medical treatment.
An insurance carrier may not prospectively inform any health care provider or pharmacy that it will not pay for a specific service, treatment or prescription when the requested service, treatment or prescription does not require preauthorization under the provisions of Rule 134.600. These instructions also apply after an injured employee has been certified to have reached maximum medical improvement. A certification of maximum medical improvement does not mean that medical treatment is no longer necessary. An injured employee remains entitled to reasonable and necessary medical treatment after the date of maximum medical improvement.
An insurance carrier that fails to confirm medical benefits coverage may commit an administrative violation pursuant to Texas Labor Code §415.002(a)(1), §415.002(a)(7), and/or §415.008. If the requested health care treatments or services do not require preauthorization under Rule 134.600, an insurance carrier that files a prospective dispute on the reasonableness or necessity of medical treatment or that informs a health care provider prospectively that it will not pay for health care services may commit an administrative violation pursuant to the sections of the Texas Labor Code cited above.
Signed this 5th day of October, 1998
Leonard W. Riley, Jr., Executive Director
Distribution:
Austin Carrier Representatives
TWCC Staff
Public Information List
Medical Professional Associations