Medical Denials in Texas Workers' Comp Claims

How to Successfully Battle Medical Treatment Denials in Texas Workers’ Compensation Cases

Often times you have to battle with insurance carrier to obtain medical treatment. The Division of Workers Compensation is responsible for processing requests for medical dispute resolution. It generally defines these disputes it processes as the disagreements between system participants involving the entitlement to workers’ compensation benefits and the amount to be paid. How the dispute is filed and processed depends upon the type of dispute as listed above.

If you have been told that the insurance company has disputed your medical treatment that means the insurance company is not going to pay benefits based on that denial. The action to resolve the disputes depends upon the type of dispute that is filed and providing the necessary information to get the treatment approved.

A medical necessity dispute concerns whether or not specific medical treatments or services are medically necessary. If there is a denial of medical necessity or denial of a preauthorization request, you must file a medical necessity dispute. An injured worker or the medical providers should submit a Request for a Review by an Independent Review Organization, TDI Form LHL009, to the insurance carrier or utilization review agent within the time period specified on the instructions for that form.

You want avoid battling the insurance carrier.. Having to fight for medical treatment will often cause delay in an injured workers’ recovery. A medical providers’ goal should be avoiding any unnecessary preauthorization disputes. The most efficient way to request preauthorization of medical testing or treatment is listed below:

  • Make sure the medical testing requires preauthorization. There are some medical services that preauthorization is unnecessary.
  • Verify the phone and fax numbers for the carrier to contact the medical requestor who will perform the requested healthcare.
  • After you have verified the correct fax number, fax your preauthorization request to the Insurance Carrier’s preauthorization department/utilization review agent.
  • Indicate the specific healthcare requested
  • Provide the medical information to substantiate the medical necessity for the requested healthcare.
  • If you are requesting preauthorization for MRI, Repeat MRI, CT Scan, EMG/NCV, or Discogram, be specific. If your request is vague, it may be denied or cause a delay in receiving medical treatment.
  • The Insurance Carrier has 3 working days day to approve or deniy treatment. f it has been more than 3 workings days, and you still have not to obtained a response from the insurance Carrier, contact the insurance carrier. The Insurance carrier must respond within three working days to some preauthorization request.

 

Remember, If the insurance carrier denies the request for preauthorization request, the medical requestor or injured worker may file a request for reconsideration with the carrier within the time period specified on the instructions for that form. If a reconsideration request is denied, the medical requestor or injured worker may appeal the denial by filing a request for an Independent Review Organization (“IRO”) by completing a form LHL009. This form is used by medical requestors and Injured Employees or persons acting on their behalf or health care providers to request a review by an Independent Review Organization (IRO) for disputes of medical necessity.

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