Just for Health Care Providers

To help streamline the billing process, complete the correct DWC billing form and make sure to fill out all required fields.

• The CMS-1500 is used for all physician services and ambulatory surgical services (use the instructions on the DWC-67).
• Use the UB-04 for all facility charges, including hospital, inpatient and outpatient services, and home health services (use the instructions on the DWC-68).
• Fill out the DWC-66 for all pharmacy services (this form already includes the proper instructions).

See DWC Rule 133.210 for documentation requirements. You will need to provide a valid state medical license number, valid diagnosis codes (ICD-9 codes), procedure codes and included modifiers for procedure codes when required. Also, provide valid NABP and FID numbers, a physical address in Box 32 for ambulance bills and use the required CPT codes from the current CPT code book.

Bills for Texas Mutual should be submitted to Jopari Solutions (payer ID: 22945). For more information, contact Jopari Solutions at (866) 269-0554.

Health care providers have 95 days from the date of service (DOS) to submit a bill and 10 months from the DOS to submit an appeal.

The denied/original EOB must be included with the original bill as proof of documentation. In most cases, the bill was denied as a duplicate due to not having the EOB attached.

There are certain situations that require both a preauthorization number and out-of-network approval on a medical bill.

Preauthorization addresses medical necessity and not compensability. There are situations when a provider can get preauthorization for conditions that are not related. Texas Mutual does not recognize preauthorization as a guarantee of payment.

If your services are set up through Align, or you have a contract with them, the bill must be submitted to the Align network.

You can retrieve claim numbers by calling our Healthcare Provider Line at (888) 53-CLAIM (532-5246) and selecting Option 2 and then Option 1.

You can access your EOB online and check the status of a bill through Texas Mutual’s Claim Status and EOB Search. You will need to provide the injured employee's social security number, FEIN, and date of service to check bill status.

Carriers have 45 days to review and process your bill. After 30 days, you can check the status of your Texas Mutual bill online or by calling (888) 53-CLAIM (532-5246)

The documentation you submitted does not support the CPT code billed. If you are billing an FCE, we confirm that the injured employee rode a stationary bike or ran on a treadmill for the cardio portion of the test. If you billed for an office visit, contact us on why the documentation did not support the CPT code.

If you are a network provider, you can fill out the WorkWell, TX network complaint form to submit a grievance about a bill. If you are not a network provider, you may file a complaint through the medical fee dispute resolution process with the Texas Department of Insurance.

Complete the preauthorization request form and attach any necessary medical documentation. You can email the form to urreferrals@genexservices.com or fax it to (855) 287-4028.

Clinical information, which validates the request, is needed in order to make a determination. Office visit notes, orders and imaging are also reviewed when making a determination.

To check the status of a preauthorization request or find out whether a procedure requires preauthorization, call (800) 844-4235.

The following services require in-network preauthorization:

• Hospital/ASC: All non-emergency hospital or ASC (inpatient, outpatient and observation) admissions including principle scheduled procedures and length of stay.
• Surgery/procedures/integral devices: All non-emergency surgeries represented by AMA CPT codes 10010-69990 and/or G codes which represent a surgical procedure performed in a setting or place of service other than the doctor's office [POS 11]. Requests should include specified hardware, implantables, external delivery system, etc. to be utilized.
  
  • All Botox Injections
  • All spinal injections (including but not limited to):
  • Epidural steroid injection
  • RFTC or cryotherapy/cryoablation
  • Sacral iliac joint injection
  • Facet injection
  • Medical branch block
  • Trigger point injections (represented by AMA CPT 20553)
  • Bone growth stimulators
  • Discograms
  • Implantable drug delivery system
  • Investigational or experimental procedures or devices as determined by Official Disability Guidelines (ODG) or listed as an AMA Category III Code.
  • Stimulator devices (including, but not limited to):
  • TENS units
  • Interferential units
  • Neuromuscular stimulators
  • Dual units
  • Spinal cord stimulator
  • Peripheral nerve stimulator
  • Brain stimulator

Physical medicine

• All chiropractic treatments
• Manipulations Under Anesthesia (MUA)
• All physical therapy/occupational therapy (unless requestor or rendering provider/facility is participating through Align)
• Biofeedback

Diagnostics

• All initial and repeat MRI and CT scans
• Bone density scans
• Unless otherwise specified in this list, all repeat individual diagnostic studies (series) having a billed amount greater than $350
• Surface Electromyography (EMG)

Other

• Durable medical equipment (DME), prosthetics and/or orthotics in excess of $500 billed charges (either purchase or expected cumulative rental)
• Gym memberships
• Texas Department of Insurance, Division of Workers' Compensation (DWC) Pharmacy Closed Formulary per 28 TAC §134, Subchapter F

Alternative treatment (including, but not limited to):

• Acupuncture that is outside of ODG
• Acupressure
• Yoga

Rehab programs (including, but not limited to):

• Work conditioning
• Work hardening
• Chronic pain management program
• Medical rehabilitation
• Brain and spinal cord rehabilitation
• Chemical dependency programs
• Weight loss programs

Nursing home (including, but not limited to):

• Skilled nursing facility, including skilled care within the same facility
• Convalescent care
• Residential care
• Assisted living
• Group homes

Psychological testing and psychotherapy (including but not limited to):

• Subsequent evaluations
• Subsequent tests or testing
• All therapy
• All biofeedback

All preauthorization requests for non-network services must be made in accordance with the Division of Workers' Compensation (the Division) Rule 134.600, which states that health care providers must obtain preauthorization for:

1. Inpatient hospital admissions, including the principal scheduled procedure(s) and the length of stay
2. Outpatient surgical or ambulatory surgical services as defined in Rule 134.600(a)
3. Spinal surgery
4. All non-exempted work hardening or non-exempted work conditioning programs
5. Physical and occupational therapy services, which includes those services listed in the Healthcare Common Procedure Coding System (HCPCS) at the following levels: Level I code range for Physical Medicine and Rehabilitation, but limited to:
   

     Modalities, both supervised and constant attendance

     Therapeutic procedures, excluding work hardening and work conditioning

     Orthotics/Prosthetics Management

     Other procedures, limited to the unlisted physical medicine and rehabilitation procedure code

6. Level II temporary code(s) for physical and occupational therapy services provided in a home setting
7. Except for the first six visits of physical or occupational therapy following the evaluation when such treatment is rendered within the first two weeks immediately following:
   

     the date of injury, or

     a surgical intervention previously preauthorized by the carrier

8. Any investigational or experimental service or device for which there is early, developing scientific or clinical evidence demonstrating the potential efficacy of the treatment, service, or device but that is not yet broadly accepted as the prevailing standard of care
9. All psychological testing and psychotherapy, repeat interviews, and biofeedback, except when any service is part of a preauthorized or Division exempted return-to-work rehabilitation program
10.  Unless otherwise specified in this subsection, a repeat individual diagnostic study:

  with a reimbursement rate of greater than $350 as established in the current Medical Fee Guideline, or

  without a reimbursement rate established in the current Medical Fee Guideline

• All durable medical equipment (DME) in excess of $500 billed charges per item (either purchase or expected cumulative rental)
• Chronic pain management/interdisciplinary pain rehabilitation
• Drugs not included in the Division's formulary
• Treatments and services that exceed or are not addressed by the Commissioner's adopted treatment guidelines or protocols and are not contained in a treatment plan preauthorized by the carrier
• Required treatment plans
• Any treatment for an injury or diagnosis that is not accepted by the carrier pursuant to Labor Code §408.0042 and §126.14 of this title (relating to Treating Doctor Examination to Define the Compensable Injury)

The following health care services require concurrent review for an extension for previously approved services:

1. Inpatient length of stay
2. All non-exempted work hardening or non-exempted work conditioning programs
3. Physical and occupational therapy services as referenced in rule 134.600(p)
4. Investigational or experimental services or use of devices
5. Chronic pain management/interdisciplinary pain rehabilitation
6. Required treatment plans

All treatments or services that do not require preauthorization or concurrent review are subject to retrospective review by the insurance carrier. Retrospective review of a provider's bill may include:

• Compliance with the Division's fee guidelines
• Compliance with the Division's treatment guidelines
• Duplicate billing
• Upcoding and/or unbundling
• Billing for treatment(s) and/or service(s) unrelated to the compensable injury
• Billing for services not documented or substantiated, when documentation is required in accordance with the Division's fee guidelines or rules in effect for the dates of service
• Accuracy of coding in relation to the medical record and reports
• Correct calculations
• Provision of unnecessary and/or unreasonable treatment(s) and/or service(s)

We follow our in-network and out-of-network preauthorization list, as well as adhere to the Official Disability Guidelines (ODG). If ODG does not recommend the treatment, then preauthorization is required.

There are certain situations that require both a preauthorization number and out-of-network approval on a medical bill. If you are missing out-of-network approval, you can complete a WorkWell, TX out-of-network request form on our providers page.

Preauthorization addresses medical necessity and not compensability. There are situations when a provider can get preauthorization for conditions that are not related. Texas Mutual does not recognize preauthorization as a guarantee of payment.

The first step to joining our health care network WorkWell, TX, is to nominate a provider on our Network Provider Nomination site. For instructions, see How to Nominate a Network Provider. The review process may take up to 30 days. 

Once you create an account, you can nominate your provider group. It takes about 30 days to review nominations, and the decision to accept or deny the provider will be sent to the email address that you used to set up the nomination.

Nominate a network provider

Call us at (888) 532-5246 for network claims filed prior to January 1, 2018.

You can refer a patient to an in-network specialist through our provider directory. You do not need preauthorization for a referral and should get out-of-network approval first if the patient is not seeing an in-network specialist.