Workers' Compensation Information for Health Care Providers
Medical Quality Review Panel (MQRP) Application for Membership
Frequently Asked Questions
- What fee guidelines have been established for Texas workers' compensation claims?
- Can I pursue a private claim with the injured worker for medical care services provided?
- As a doctor, what is my role in Return to Work?
- What is the Approved Doctor List (ADL)? As a doctor, if I am not on the Approved Doctor List, can I provide medical care services to an employee with a work-related injury and be compensated for such services?
- What is a Designated Doctor? How do I become one?
- If I am a doctor participating on the ADL, can I perform impairment ratings?
- As a doctor who treats injured workers, what forms do I need to file for workers' compensation?
- What is preauthorization?
- What is Fraud under Texas workers' compensation?
- What is medical dispute resolution?
- What is the new rule about Prospective Review of Medical Care Not Requiring Preauthorization (PRM)? When would I use that process?
- As an administrator to a doctor who treats injured workers, how do I stay informed of Texas workers' compensation procedural changes, form changes, etc.?
1. What fee guidelines have been established for Texas workers' compensation claims?
The Texas Department of Insurance, Division of Workers' Compensation (the Division) has adopted a medical fee guideline; acute care inpatient hospital fee guideline; ambulatory surgical center fee guideline, and a guideline on pharmaceutical benefits.
Related Questions
Where can I find out more information about the Medical Fee Guideline (MFG)?
The Medical Fee Guideline (Rule 134.202) provides the ground rules for coding, billing, and reporting instructions for professional medical services. To purchase a copy of the Medical Fee Guideline Rule 134.202, you may contact Division Publications at (512) 804-4240. A current list of Division publications available for purchase can be viewed on the publication price list.
For the most part, the MFG does not provide actual CPT codes and/or maximum allowable reimbursement (MAR) amounts. To determine the reimbursable rate for CPT codes valued by Medicare, multiply the amount Medicare allows a participating physician or supplier in either a facility or non-facility setting by the Division multiplier of 125%, (with some exceptions).
The Medical Fee Guideline Online Training Module is designed to help system participants gain an overall understanding of the concepts significant to the Medical Fee Guideline (MFG). The MFG training module provides instructions on how to use Medicare policies; the precedence of the Texas Workers' Compensation Act and Rules over Medicare policy; continuous Medicare program updating; and medically necessary and reasonable health care for injured workers.
The Medical Fee Guideline Frequently Asked Questions are intended to be a quick reference to answer Health Care Provider's questions on frequently encountered situations.
Will the Division publish a MFG with CPT codes and Maximum Allowable Reimbursement (MAR) amounts?
No. The information necessary for billing and reimbursement in the Medicare system is available through the Centers for Medicare and Medicaid Services (CMS) website online at http://www.cms.hhs.gov/center/provider.asp. In general, CPT codes and Medicare rates change on an annual basis, and changes can be found on the CMS website.
In addition, the Medicare contractor, TrailBlazer Health Enterprises, provides a Medicare online fee schedule tool to look up procedure code values by year, state, and locality at http://www.trailblazerhealth.com/Agreement.asp?preRegistrationDestination=%2Flogin%2Easp%3F.
Information regarding the Medicare guidelines for durable medical equipment (DME) can be found at http://www.palmettogba.com and http://www.cms.hhs.gov/MedicareProviderSupEnroll/.
Where can I get a CPT code book?
The CPT code book can be purchased online from the American Medical Association (AMA) at http://www.ama-assn.org/ama/pub/category/4555.html.
What conversion factor should be used in applying the Division multiplier?
The Division adopted a multiplier of 125% of the effective Medicare conversion factor. The Medicare conversion factor is generally updated in November and is effective the following January.
The Medical Fee Guideline Rule 134.202(c) provides the following instructions:
"To determine the maximum allowable reimbursements for professional services, system participants shall apply the Medicare payment policies with the following minimal modifications:
(1) for service categories of Evaluation & Management, General Medicine, Physical Medicine and Rehabilitation, Surgery, Radiology, and Pathology, the conversion factor to be used for determining reimbursement in the Texas workers' compensation system is the effective conversion factor adopted by Centers for Medicare and Medicaid Services multiplied by 125%. For Anesthesiology services, the same conversion factor shall be used."
Where can I find out more information about the pharmaceutical benefits?
A complete listing of pharmaceutical benefits including definitions, initial pharmaceutical coverage, pharmaceutical services, reimbursement methodology, pharmaceutical expenses incurred by the injured worker, and outpatient drug formulary is located under Pharmaceutical Benefits, Rules 134.500 through 134.506.
An overview of the requirement for over-the-counter or generic versus brand name drugs, reimbursement methodologies, and important definitions can be found under Fast Facts: Pharmacy.
Where can I find out more information about the Acute Care Inpatient Hospital Fee Guideline and Ambulatory Surgical Center (ASC) Fee Guideline?
The Acute Care Inpatient Hospital Fee Guideline (Rule §134.401) applies to all reasonable and medically necessary medical and/or surgical inpatient services to treat work-related injuries in an acute care, inpatient hospital setting.
The Ambulatory Surgical Center (ASC) Fee Guideline (Rule §134.402) addresses facility services provided by an ambulatory surgical center on or after September 1, 2004. This guideline is not applicable to professional medical services performed in an ASC setting.
In addition, the Medicare determined Texas Ambulatory Surgical Center Localities are available for your viewing to assist in determining the reasonable charge locality and physician fee locality in your area for the purpose of calculating ASC rates.
back to top
2. Can I pursue a private claim with the injured worker for medical care services provided?
A medical care provider may not pursue a private claim against an injured worker for all or part of the cost of the health care services provided in most cases. Actions that would indicate pursuit of a private claim include:
1. Sending a bill to an injured worker when an information copy was not requested by the worker.
2. Contact by a health care provider trying to collect money for services.
3. Letters sent to the claimant from a collection agency.
4. Filing a lawsuit in court.
5. Filing a claim with the injured worker's private health insurance.
A health care provider may pursue a private claim only when the work-related injury is finally adjudicated by the Division as non-compensable. Pursuing a private claim when the work-related injury has not been adjudicated by the Division as non-compensable is a Class B administrative violation and subject to a penalty of $5,000.
back to top
3. As a doctor, what is my role in Return to Work?
Encouraging an injured worker to stay at work or return to work is one of the services a doctor can provide to an injured worker. The longer an injured worker is off work, the less likely it is that he or she will ever return to productive employment. By encouraging the employee to engage in normal activity as much as possible, the doctor will help to shift the employee's focus away from the injury and toward functional recovery and returning to work.
As the treating doctor, you must determine what work is medically safe and appropriate for the injured worker to perform. You must complete a work status report (form DWC 73) after the injured worker's initial visit, when there is a change in the injured worker's work restrictions, and when the injured worker's work status changes.
Injured workers who continue to do appropriate work while they are healing recover faster and better than those who remain off work. The Division website contains useful information on Return to Work to assist health care providers, employers, and injured workers become more knowledgeable about the advantages and benefits of staying at work, if possible while recovering or returning to work early and how to make those efforts successful.
Related Questions
What is Stay at Work versus Return to Work?
The purpose of stay at work is to prevent as much lost time from work by an injured worker as possible. In most instances, continuing to perform appropriate work as part of an injured worker's treatment can assist them in recovering faster and better than if he/she remained away from work for an extended period of time. The idea is to change the expectation of the injured worker from missing work because of an injury to engaging in staying at work. As a doctor, talk to the injured worker about what parts of their work they may be able to continue to perform. The employer may be able to provide part time work, allow the injured worker to work at a reduced pace, or complete other meaningful tasks.
Unfortunately, there will be instances when injured workers are unable to participate in work activities due to the nature of their injury. In these instances, the objective of Return to Work is just that, returning the injured worker to meaningful work that is medically safe and appropriate, and within the injured workers capabilities, as soon as possible.
What is the purpose of the Work Status Report (DWC-73)?
The intended purpose of the Work Status Report form (DWC-73) is to:
- Improve communication among doctors, employers and employees so that they may facilitate injured workers' effective and appropriate stay at work/return to work;
- Provide an assessment of the injured worker's capabilities so the employer can make the appropriate employment decisions; and
- Provide a standard reporting system for work status within the Texas workers' compensation system.
When is the Work Status Report (DWC-73) to be filed?
Generally, only treating doctors and referral doctors file the Work Status Report (DWC-73). The four instances in which the treating or referral doctor must file the DWC-73 include:
- The injured worker's initial visit;
- When the injured worker's activity restrictions change;
- When the injured worker's work status changes; and
- On the schedule requested by the insurance carrier, which shall not exceed one report every two (2) weeks and be based upon the doctor's scheduled appointments with the injured worker.
What information do I need to provide on the DWC-73 about an injured worker's work status?
To be considered complete, the DWC-73 must include the following information about an injured worker's current work status:
- Identification of the employee's functional abilities so that the employer can determine work opportunities;
- Effective dates and estimated expiration dates of current functional status and restrictions;
Identification of applicable activity restriction, or an explanation of how the employee's compensable injury prevents the employee from returning to work in any capacity; and
- General claim-identifying information such as the injured worker's name, date of injury, doctor's name and degree, employer's name, etc.
back to top
4. What is the Approved Doctor List (ADL)? As a doctor, if I am not on the Approved Doctor List, can I provide medical care services to an employee with a work-related injury and be compensated for such services?
For a doctor to be eligible to provide health care services to employees with work-related injuries and be compensated for medically necessary medical care, you must be a "doctor" on the Division's Approved Doctor List. "Doctor" means a doctor of medicine, optometry, dentistry, podiatry, osteopathic medicine, or chiropractic who is licensed and authorized to practice. Other types of health care providers may also provide medical care if the care they are providing is performed at the direction of a doctor who is on the Division's Approved Doctor List. Rule 180.20 describes the ADL process.
However, if a work-related injury or illness is an emergency, you may provide medical care to the injured worker without being on the Approved Doctor list. An emergency is the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health and/or bodily function in serious jeopardy, and/or dysfunction of any body organ or part.
Related Questions
How do doctors apply to be on the Approved Doctor List (ADL) using TXCOMP?
Doctors wishing to apply to be on the ADL may access the Step-by-Step Instructions to apply for Division ADL. Here doctors will find detailed information on how to complete the application process that is necessary for admission onto the Texas Department of Insurance, Division of Workers' Compensation's Approved Doctor List.
As an additional reference, doctors may view the New Requirements for Participating Doctors in Texas workers' compensation.
A complete list of topics and tools available on the TXCOMP system can be found at http://www.tdi.state.tx.us/wc/txcomp/help/hlp_home.html. To access the TXCOMP system directly, click on the following link: TXCOMP. For assistance, please call 1-888-4TXCOMP (1-888-489-2667).
What is meant by financial disclosure?
To participate in the Texas workers' compensation system, each doctor is required to disclose to the Division, the identity of any health care provider in which the doctor has a financial interest, an immediate family member of the doctor who has a financial interest, or the health care provider that employs the doctor who has a financial interest. For more information, click on Fast Facts: Financial Disclosure.
Is training available to doctors who want to be on the Approved Doctor List?
Yes. Two levels of training are available for doctors accepted onto the Approved Doctor List. The ADL Level 2 Doctor Training Module is required for doctors participating on the ADL who treat more than 18 injured workers per year. The ADL Level 1 Doctor Training Module: Limited Participation is required for doctors participating on the ADL who treat 18 or fewer injured workers per year.
back to top
5. What is a Designated Doctor? How do I become one?
A Designated Doctor is a doctor, selected by the Division, who helps resolve issues regarding maximum medical improvement (MMI), impairment rating (IR), and return to work during the supplemental income benefits (SIBS) period. To become a Designated Doctor, you must meet all of the Designated Doctor List requirements.
back to top
6. If I am a doctor participating on the ADL, can I perform impairment ratings?
To assign an impairment rating, a doctor must meet all impairment rating requirements, be on the ADL, and be authorized and approved by the Division to perform impairment ratings. A doctor whom Division has not certified to assign impairment ratings is only authorized to determine whether an injured worker has permanent impairment and, in the event that the injured worker has no impairment, certify maximum medical improvement.
Related Question
- After I complete the IR training and take the IR test, can I perform impairment ratings?
After you have completed the IR training and passed the IR test, you will need to apply for authorization to assign impairment ratings and to be on the ADL. The instructions specifying how to apply for IR authorization online can be found in the TXCOMP system at http://www.tdi.state.tx.us/wc/txcomp/help/hlp_home.html#14. After completing the online application, you will receive electronic notification from Division on the outcome of your application.
Following are the current impairment rating education seminars and testing schedules.
back to top
7. As a doctor who treats injured workers, what forms do I need to file for workers' compensation?
A complete list of Texas workers' compensation forms for health care providers and their purpose can be found on the Division Forms Page.
The most frequently used forms by health care providers include:
Report of Medical Evaluation (DWC-69)
Work Status Report (DWC-73)
Medical Dispute Resolution Request / Response (DWC-60)
Instructions for Completing the CMS-1500
CMS-1500 Claim Form
back to top
8. What is preauthorization?
Preauthorization is prospective approval of medical care service(s) based entirely upon medical necessity. Preauthorization is obtained from an insurance carrier by the requestor, such as the treating doctor, or injured worker, before the medical care is provided. Following is a link to the Preauthorization Rule 134.600. An overview of preauthorization, concurrent review, voluntary certification, and the requirements of each, can be found in Fast Facts: Preauthorization.
Related Questions
Do I need to have preauthorization to treat an injured worker?
Certain medical services require preauthorization. A list of medical services requiring preauthorization can be found under subsection (h) of Preauthorization Rule 134.600.
Work hardening and work conditioning programs certified by the Division on Accreditation of Rehabilitation Facilities (CARF) and approved for exemption by the Division, are exempt from obtaining preauthorization. A list of the Work Hardening/Work Conditioning Programs Exempt from Preauthorization is located on the Division website.
Are there any exceptions to the preauthorization requirements?
Yes. If an injured worker has a medical emergency that poses a risk to their life, you may provide medical care services without obtaining preauthorization.
What constitutes a medical emergency?
A medical emergency consists of the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health and/or bodily function in serious jeopardy, and/or dysfunction of any body organ or part.
Health care services and treatment were preauthorized but now the insurance carrier will not pay for the treatment provided. What can I do?
If the insurance carrier denies payment for health care services as not medically necessary that they preauthorized as medically necessary, resubmit the charges and preauthorization approval to the insurance carrier. If the insurance carrier continues to deny payment on the preauthorized health care services as not medically necessary, submit the billed charges,
Medical Dispute Resolution Request/Response form DWC-60 Medical Dispute Resolution Form DWC-60, explanation of benefits, and preauthorization approval to the Division to begin the Medical Dispute Resolution Process for Medical Fees and Medical Necessity. Denying preauthorized health care services is an administrative violation in accordance with Rule 133.301(a). When a medical dispute resolution request is received by the Division for preauthorized heath care services that have been denied, a referral will be made to Compliance & Practices (C&P) for the violation.
However, if the insurance carrier denies payment on the preauthorized medical care services for reasons of compensability or extent of injury, the injured worker will need to contact their local field office's Customer Assistance at 1-800-252-7031 to begin the Medical Dispute Resolution Process for Medical Fees and Medical Necessity.
back to top
9. What is Fraud under Texas workers' compensation?
Fraud occurs when a person knowingly or intentionally conceals, misrepresents, or makes a false statement to either deny or obtain workers' compensation benefits or insurance coverage, or otherwise profit from the deceit. For additional information on Texas workers' compensation fraud, visit the fraud page.
back to top
10. What is medical dispute resolution?
Medical Dispute Resolution is the request to resolve a dispute related to medical fees or medical necessity after reconsideration has been requested and denied by the insurance carrier. A medical necessity dispute may be a prospective medical necessity or retrospective medical necessity dispute. Please click on the following links to find more information on Medical Fee Disputes and Medical Necessity Disputes.
Related Questions
How do I file a medical dispute resolution request?
If a dispute arises over medical fees or the medical necessity of a claim, the Division administers a Medical Dispute Resolution process to resolve the issue. The Medical Dispute Resolution Request/Response form (DWC-60) and instructions on completing the form can be found on the forms page.
How much time do I have to file the medical dispute resolution request?
All requests for retrospective medical dispute resolution must be no later than one (1) year after the date of service(s) in dispute. See Rule 133.307(d)(1).
How do I appeal the Medical Dispute Resolution decision?
If you are dissatisfied with the decision issued by Medical Dispute Resolution, you may request a hearing before the State Office of Administrative Hearings. This request must be filed with the Division's Chief Clerk of Proceedings no later than 20 days from the date you received the decision. Follow the instructions entitled "Your Right to Request a Hearing" which appear on the first page of the decision.
How can I find out more about Medical Dispute Resolution?
The Division has developed an introductory slide presentation and a detailed slide presentation to assist workers' compensation system participants in understanding the Medical Dispute Resolution process. The introduction presentation provides a general overview of how the Texas Labor Code and the Division Rules lay out provisions relating to the Medical Dispute Resolution process.
The detailed presentation identifies the different types of medical disputes, including those that require review by Independent Review Organizations. The presentation addresses the steps to follow when filing a Medical Dispute Resolution request. This process is for health care providers, insurance carriers, and injured workers who seek further review of disputed medical care or reimbursement.
back to top
11. What is the new rule about Prospective Review of Medical Care Not Requiring Preauthorization (PRM)? When would I use that process?
Rule 134.650 created a voluntary process which is available to doctors providing medical care to an injured worker which:
- does not require preauthorization,
- has not yet been provided,
- is to treat a current medical condition that is related to the compensable injury, and
- for which the carrier has indicated an intent to deny reimbursement.
A form DWC-49 is necessary to begin the PRM process, which is handled by the local field office. For additional information, please see the PRM page.
back to top
12. As an administrator to a doctor who treats injured workers, how do I stay informed of Texas workers' compensation procedural changes, form changes, etc.?
Numerous resources exist to help keep you up to date with new developments and changes affecting Texas workers' compensation. On the Texas Department of Insurance, Division of Workers' Compensation website, you will find Bulletins and Advisories clarifying prior rules and laws, and recent changes and postings on the Division website under the "What's New" section.
The Seminars and Education Programs provides information regarding online training modules, as well as, upcoming seminars and training events. Registering with Trailblazer Health Enterprises, the Texas Medicare carrier, you will receive weekly notifications detailing any changes to Medicare procedures and policies.
To receive advisories, seminar announcements, news, and other information for Texas Workers' Compensation system participants, you may request to be placed on the Public Information mailing list by sending a request to that includes your name, organization, phone number, fax number, and email address.
back to top
Other Resources
Centers for Medicare & Medicaid Services (CMS) Fee Schedules
CARF Accredited Programs exempted from Preauthorization
Palmetto GBA Durable Medical Equipment Site Resources
Texas Medicare Carrier - Trailblazer Health Enterprises
Texas State Board of Medical Examiners
For more information contact: Webstaff@tdi.state.tx.us
Texas Department of Insurance
