IMO MED-SELECT NETWORK A Certified Texas Workers Compensation Health Care Network PROVIDER MANUAL

Transcription

1 IMO MED-SELECT NETWORK A Certified Texas Workers Compensation Health Care Network PROVIDER MANUAL

2 TABLE OF CONTENTS Letter from the President... 3 Provider Philosophy and Mission... 4 Quick Reference Guide... 5 Contact Information... 7 Service Areas... 7 Injured Employee Requirements for In-Network Providers... 9 New Injury Process... 9 Prior Injuries... 9 Case Management... 9 Treatment Guideline Disability Duration (Return to Work) Guideline...10 Responsibilities of Treating Doctor...11 Role of Specialist...12 Selection of Treating Doctor...13 Change of Treating Doctor...13 Request for Initial or Alternate Treating Doctor Form...15 Request for Subsequent Change in Treating Doctor Form...16 Selection of Specialist as a Treating Doctor...17 Specialist as a Treating Doctor Form...18 Out-of-Network Specialists...19 Request for Out-of-Network Specialist Form...20 Preauthorization...21 Preauthorization Network Request Form...25 Compensability of the Injury...26 Medical Bill Submission and Payment...26 Complaints and Fee Disputes...28 Complaint Form...30 Medical Necessity Disputes...31 Provider List...31 Quality Improvement Program...32 Workers Compensation Information and Websites Revised

3 Dear Provider, I would like to officially welcome you to the IMO Med-Select Network. We are honored you have joined our team! Injury Management Organization, Inc. (IMO) is a comprehensive managed care company committed to promoting quality health care and wellness toward a safe and productive return to work. It is our mission to serve clients and injured employees while ensuring our managing partners and providers share common goals and strive for successful outcomes. You are receiving this letter and provider manual because you have been credentialed and contracted in the IMO Med-Select Network. We would like to further share our philosophy to make certain our network mission is thoroughly outlined. Core objectives include the following: To provide quality delivery of care at all times and provide effective treatment that is essential for a healthy recovery and successful return to work. To enhance communication while collaborating with IMO medical case managers and the injured employee to ensure satisfaction of care is obtained at all times. To be committed to medical utilization of Evidence Based Guidelines (EBG) with the Official Disability Guidelines (ODG), the Medical Disability Guidelines (MDG) or other network adopted guidelines while remaining in compliance with the Texas Insurance Code and rules of the Texas Department of Insurance (TDI). To participate in the Quality Improvement Program (QIP) process, while continuing to manage and evaluate effectiveness of medical necessity and medical bill audits. Provider Directory Defined You may be identified as a treating doctor meaning you are a licensed Medical Doctor (MD) or a Doctor of Osteopathy (DO). If a specialist, you may fall under Family Practice/Medicine, General Practice, Internal Medicine or Occupational Medicine. If in El Paso, Physical Medicine and Rehabilitation (PM&R) is an option. A specialist is also chosen for a specific specialty (e.g. orthopedics, physical medicine and rehabilitation, pain management, chiropractic, physical or occupational therapist). Included in this list are doctors who are or have been trained and tested to certify MMI/Impairment Ratings. Furthermore, the IMO Med-Select Network credentials and contracts diagnostic facilities, urgent care facilities, hospitals, and ambulatory surgery centers. Please do not hesitate to contact the IMO Med-Select Network at netcare@injurymanagement.com or with questions. We look forward to building a strong partnership and appreciate your interest in making this endeavor a mutually gratifying one. Respectfully, Catherine Benavidez President & CEO 3 Revised

4 IMO Med-Select Network Provider Philosophy and Mission Mission Statement: It is the mission of IMO and its provider network to ensure the delivery of excellent quality health care and a safe stay at work/return to work for the injured employee. Quality Medical Care: We strive to provide quality treatment care plans that use evidence based guidelines such as the Official Disability Guidelines (ODG) and the Medical Disability Guidelines (MDG). The network may select other evidence based practice guidelines as warranted. Case Manager: Injured employees may be assigned a Telephonic Case Manager (TCM) and, if necessary, field case management based on the needs and severity of the injury. The IMO Certified Case Manager (CCM) will coordinate effective communication between all parties and will focus on accelerating prescribed treatment and preventing lost time through education as well as facilitating a safe return to work. Return to Work: To proactively encourage stay at work, but, when need arises for lost time, quickly develop a Return to Work plan (including the use of the Medical Disability Guidelines), understanding the urgency to return employees to a work setting. Provider Report Card/Performance: We emphasize the serious importance of impacting the lives we touch with measurable results. Performance Based Measures (PBM) is the usual methodology used to ensure accountability for outcomes and results. The PBM report card will be available for review by both IMO and the Division of Workers Compensation (DWC) on an annual basis. The report card can be found at The areas of measurement include the following: Satisfaction of Care: Communication, wait time, professional demeanor, compassion and satisfaction with the progress of care. Utilization: Appropriate utilization of services by diagnosis according to evidence based guidelines. Health Care Costs: Overall cost of care considering duration and medical necessity. Access to Care: Availability and accessibility of providers. Return to Work: Lost time prevention or early Return to Work in order to promote effective recovery. Use of the guidelines for benchmarking and prognosis for Return to Work is essential. Health Outcomes: Overall health outcomes as it relates to physical and mental wellbeing. Teamwork and Accountability: As the selected provider, and a key member of the medical team, your close adherence to the network expectations and standards will help ensure quality medical delivery. We encourage and appreciate your feedback and partnership. 4 Revised

5 IMO Med-Select Network Quick Reference Guide Texas Workers Compensation Health Care Networks are certified by the Texas Department of Insurance (TDI) and are mandated to follow specific requirements spelled out in Texas Insurance Code, Chapter 1305, the Texas Workers Compensation Act, and corresponding administrative rules. A network is defined as an organization that is formed to provide health care services to injured employees and is established by, or operating under contract with, an insurance carrier. Injury Management Organization (IMO) is a certified Utilization Review Agent (URA) and is the parent company to IMO Med-Select Network. Hence, the preauthorization, case management and medical bill review processing is provided internally at IMO. Network Treating Doctors: All treating doctors in the network are licensed as a Medical Doctor (MD) or a Doctor of Osteopathy (DO). In order to be a treating doctor, the physician must be a Family Practitioner, General Practitioner, Internal Medicine Specialist, Occupational Medicine Specialist or Physical Medicine and Rehabilitation Specialist (PM&R in El Paso Only). Treating Doctor Selection and Change: The injured employee chooses a treating doctor from the network provider List. He or she may change the treating doctor once without approval but must receive approval after one change. Referrals to Specialists: All referrals to specialists are approved by the treating doctor. appointments are to be set within 21 days. Specialist Notice for Injured Employees by Employers: According to Texas statutes, each provider is required to post a notice regarding the IMO Med-Select Network. Employers are required to provide detailed network information not only to each new employee but also to any employee that is injured. Office Posting of Complaint Process: Each provider in the network is required to post a notice to injured employees on the network complaint resolution process in their office. Case Management (New Injury Process): A network case manager will be assigned cases based on severity levels. The case manager will act as a liaison between the injured employee, employer, providers and insurance carrier. The network must have certified case managers as part of its staff. An adjuster cannot be a case manager in the network. Evidence Based Guideline (EBG): Providers are required to provide treatment in accordance with EBG. Medical Disability Guideline (MDG): Providers should use the disability duration tables in the MDG to discuss stay at work and return to work strategies with the injured employee, the employer, and the case manager. Stay at Work / Return to Work: Treating doctors must discuss stay at work / return to work expectations with injured employees, employers and carriers, encouraging system participants to explore options for restricted and modified assignments. 5 Revised

6 Preauthorization of Certain Treatments and Services: Prospective approval (preauthorization) of certain treatments and services is required. The time frames are mandated by statute but the network s required list of preauthorization treatments and services varies from the required list for non-network care. Medical Bill Submission, Processing and Review: All requirements, including the forms to submit and time frames for billing and payment, follow the administrative rules of the Division of Workers Compensation (DWC). Billing Information: The network does not pay the medical bills submitted for reimbursement. The medical bills should be addressed to the appropriate insurance carrier, third party administrator, or certified self-insured employer handling the compensable claim. Medical Treatment and Fee Disputes: All disputes regarding payment for medical services are handled internally within the network. All disputes regarding medical necessity of the treatment, either before or after providing the treatment, are handled by the Texas Department of Insurance (TDI). Provider List: The network provider list is available at Service Area: The network service area is defined as the specific Texas counties in which the network is certified by the State of Texas. If a covered injured employee lives in one of those counties, that injured employee must receive care by a contracted network provider. Credentialing and Contracting: The network has a comprehensive process for credentialing all providers including the primary verification of the provider s education, training and licenses, all certifications, as well as claims and sanctions. All providers are presented to the Credentialing Committee for review and possible approval. Contracts are negotiated individually according to the needs of the network and the provider or facility. Providers are paid according to the individually negotiated contracts. Financial Disclosure: By Texas statute, a network doctor must disclose the identity of any health care provider in which: 1) the network doctor has a financial interest, 2) any immediate family member of the network doctor that has a financial interest, or 3) the provider that employs the network doctor has a financial interest. Nominating a Provider for the Network: You can nominate another provider for possible credentialing and contracting by submitting his or her name, address, number and information via IMO s website at Click the Network Provider Nomination Form option on homepage. Quality Improvement Program: The Texas Department of Insurance (TDI) mandates that networks have a Quality Improvement Program (QIP). This includes developing a plan for analyzing clinical trends as well as compliance with treatment and return to work guidelines. 6 Revised

7 IMO Med-Select Network Contact Information Address: IMO Med-Select Network P.O. Box Carrollton, TX Telephone Numbers: 1. Network Main Line: or Customer Care: or Network Direct Fax: or IMO Main Line: or Addresses: 1. Main Network Address: 2. Complaints: 3. Staff: All s at IMO are the person s first initial and last name, followed Website: Visit the website for new information about Injury Management Organization, Inc. and the IMO Med-Select Network. Service Areas 1. The network operates in the following counties or service areas: 1. Atascosa 2. Austin 3. Bandera 4. Bastrop 5. Bell 6. Bexar 7. Blanco 8. Brazoria 9. Brazos 10. Burleson 11. Burnet 12. Caldwell 13. Cameron 14. Chambers 15. Colorado 16. Collin 17. Comal 18. Dallas 19. Denton 20. El Paso 21. Ellis 22. Falls 23. Fayette 24. Fort Bend 25. Galveston 26. Gonzales 27. Grayson 28. Grimes 29. Guadalupe 30. Harris 31. Hays 32. Henderson 33. Hidalgo 34. Hill 35. Hood 36. Hunt 37. Jefferson 38. Johnson 39. Karnes 40. Kaufman 41. Kendall 42. Lee 43. Liberty 44. Limestone 45. Medina 46. McLennan 47. Milam 48. Montgomery 49. Navarro 50. Parker 51. Rains 52. Robertson 53. Rockwall 54. San Jacinto 55. Smith 56. Starr 57. Tarrant 58. Travis 59. Van Zandt 60. Walker 61. Waller 62. Washington 63. Wharton 64. Williamson 65. Wilson 66. Wise 67. Wood 7 Revised

8 2. If the injured employee lives outside of the network service area, he or she is not required to seek care from network providers. If the employee is hurt at work and does not believe that he or she lives within the Network service area, the injured employee should call their insurance carrier. The insurance carrier must review the information within seven days and contact the injured employee. The term lives is defined by administrative rule of the Texas Department of Insurance (TDI): Where an employee lives includes: (A) the employee's principal residence for legal purposes, including the physical address which the employee represented to the employer as the employee's address; (B) a temporary residence necessitated by employment; or (C) a temporary residence taken by the employee primarily for the purpose of receiving necessary assistance with routine daily activities because of a compensable injury TAC 10.2(a)(14) 3. If an injured employee must reside outside of the service area temporarily, the network case manager will discuss the injured employee s needs with the injured employee, providers involved in the employee s care, the employer and carrier. If the reason for the change in location is because of a need for assistance with activities of daily living, the case manager will evaluate the need for this location and when the injured employee may be able to return to the permanent residence in the service area. 4. If the insurance carrier and injured employee disagree, the injured employee may file a complaint with the Texas Department of Insurance (TDI). 5. The employee may receive health care from network providers while the employee s complaint is being reviewed. 8 Revised

9 Injured Employee Requirements for In-Network Providers 1. If a worker is hurt at work and lives in the network service area, he or she must choose a treating doctor from the list of network doctors. All services and referrals are to be received from the treating doctor. 2. If an injured employee needs a specialist, the treating doctor must make the referral. The injured employee must go to the health care providers in the network (with certain exceptions, including emergencies). 3. If emergency care is necessary, the injured employee may seek treatment anywhere. 4. If an injured employee needs urgent care after hours and cannot contact his or her treating doctor, the injured employee is instructed to go to the closest health care facility. 5. The insurance carrier will pay the network treating doctor and other network health care providers. Except for emergency care, an injured employee may be responsible for payment of care provided by a non-network doctor without network approval. 6. Network providers may bill only the insurance carrier for treatment related to a work injury. Network providers may not bill an injured employee for such treatment. 7. If a treating doctor decides to leave the network and it may harm an injured employee with an acute condition to stop treating with that doctor immediately, the carrier must pay the treating doctor for up to 90 days of continued care. If there is dispute about this continued care, it will be handled through the network s complaint process. New Injury Process When an employee is injured on the job, the insurance carrier or Third Party Administrator (TPA) is the first party outside of the employer s facility to receive notice of the injury. Depending upon the employer, the network is contacted within 24 to 48 hours after the carrier or TPA is notified. Unless it is a minor injury, the network will contact the employee, the treating doctor, and the employer regarding the injury and treatment. The network will make this contact even if the adjuster of the carrier or the TPA has also contacted the parties involved. Prior Injuries Depending upon insurer s preference, the network may include employees that were injured before the insurer joined the network. If this occurs, the injured employees will be notified by their employer of the network s role. Case Management A network case manager will be assigned cases based on severity levels. The case manager will act as a liaison between the injured employee, employer, providers and insurance carrier. The provider is expected to work with the case manager without additional costs. 9 Revised

10 Treatment Guideline 1. Evidence Based Guidelines (EBG): Network providers are contractually obligated to follow the EBG such as the ODG. Hence, in most circumstances where the treatments and services are recommended by the ODG, the provider should be reimbursed for that care. Conversely, the provider will not be reimbursed for any treatment, service, or durable medical equipment that falls outside of, or is not recommended by, EBG unless the provider obtains preauthorization prior to providing the treatment or service. An EBG should be consulted prior to requesting preauthorization. The network does have the authority to utilize various approved evidence based practice guidelines when warranted. 2. The ODG can be ordered at Even though both a print version and webbased version are available, the network advises the purchase of a web-based version because it is updated frequently throughout the year. The printed version is updated annually. Disability Duration (Return to Work) Guideline 1. Network providers are contractually obligated to follow the Medical Disability Guidelines, Workplace Guidelines for Disability Duration (MDG) in assessing appropriate duration of disability. Disability durations under the MDG vary depending on the diagnosis and the demands of the job (for example, a patient with a back strain whose job is classified as sedentary will have a shorter expected disability duration than a patient with the same diagnosis whose job is classified as heavy work). 2. The MDG will be used by the network case managers when discussing stay at work, return to work and modified duty assignments. The MDG will also be used by adjusters to discuss disability duration. Network providers should use it when discussing the same issues with their patients. 3. Information regarding ordering the MDG can found at or by calling The MDG is also in hard copy and in web-based form. It does not change as often as the ODG, but the web-based form is always the most current. 10 Revised

11 Responsibilities of Treating Doctor (Selected by the injured employee) 1. The treating doctor is a doctor who is primarily responsible for the injured employee's health care that relates to the injury. 2. In the IMO Med-Select Network, all treating doctors are licensed as a Medical Doctor or a Doctor of Osteopathy. In addition, the network treating doctor must be a Family Practitioner, General Practitioner, Internal Medicine Specialist, Occupational Medicine Specialist or Physical Medicine and Rehabilitation Specialist (PM&R in El Paso Only). All other physician specialists and ancillary health care professionals are referral or consultant providers. 3. The responsibilities of the treating doctor include the following: a. Provide health care to injured employees for the compensable injury within acceptable medical standards; b. Hold the appropriate license and practice within their scope of practice; c. Accept responsibility to coordinate the injured employee s health care needs; d. Participate in the medical case management process as required by the network; e. Approve or recommend all treatment by providing a treatment care plan. Please contact IMO if you need assistance with this. If you would like the IMO Netcare20 Treatment Care Plan, please call the network TCM; f. Maintain efficient utilization of care; g. Obtain approval for preauthorization as listed. An expedited preauthorization may be requested for urgent scenarios. See list and Preauthorization Forms for access and directions; h. Communicate with the injured employee, employer, adjuster and network as necessary; i. Work with Evidence Based Guidelines: To include Official Disability Guidelines (ODG) for medical treatment guidelines and the Medical Disability Guidelines (MDG) for the return to work guidelines; j. Encourage a stay at work and return to work plan; k. Perform the impairment rating and work status if certified to perform impairment ratings; l. Refer within network, unless not accessible. Specialist appointments must be scheduled within 21 days; m. Consult and obtain approval with the network TCM when a specialist is referred; n. Make available to the network: i. Treatment care plan / work release data ii. Cost and utilization data iii. Patient satisfaction data 11 Revised

12 Role of the Specialist (Referred by the treating doctor) Specialist should be referred by the treating doctor; Treat the injured employee for the diagnosis or body part as specified by the treating doctor; Provide a comprehensive consultation with recommended treatment for the compensable injury; Utilize Evidence Based Guidelines such as Official Disability Guidelines (ODG) for medical treatment and Medical Disability Guidelines (MDG) for return to work guidelines; Collaborate with the injured employee s treating doctor on treatment plan recommendations; Obtain approval for preauthorization as listed. An expedited preauthorization may be requested for urgent scenarios. See list and preauthorization Forms for access and directions; Release the injured employee back to the treating doctor when no further specialist care is required; Not refer a patient to another doctor; Not determine work status unless he / she has been approved as the treating doctor. A specialist can perform an Impairment Rating if requested by the treating doctor and is indeed certified to perform an Impairment Rating. 12 Revised

13 Selection of Treating Doctor 1. Injured employees have the right to select their treating doctor at the time of the injury. The first treating doctor selected by the injured employee is considered the initial choice of treating doctor. 2. The injured employee may select a treating doctor by: a. Choosing a doctor from the network provider list available at or b. Requesting assistance from the network or employer / adjuster. 3. The following do not constitute the injured employee s choice of treating doctor: a. A doctor salaried by the employer, b. A doctor providing emergency care, or c. Any doctor who provides care before the employee is enrolled in the network. 4. In the network, there is no 60-day time frame for the initial choice of treating doctor as there is in non-network Workers compensation. 5. If the injured employee has a life-threatening injury or chronic pain related to the compensable injury, he or she may apply to the network s Medical Director to use a non-primary care physician specialist that is in the network as his or her treating doctor. Change of Treating Doctor 1. A referral to a specialist or consultation by another doctor requested by the treating doctor is not considered a change in treating doctors. 2. The injured employee may change from their initial choice to an alternate choice of treating doctor by notifying the network. The network will not deny a selection of this one (or alternate ) change of treating doctor through the network. 3. After the change to an alternate treating doctor, if the injured employee is still dissatisfied, he or she must request and receive permission from the network to change treating doctors. 4. Some of the criteria that the network will use to determine if a change to a third treating doctor is appropriate (after the initial and alternate choices) are: a. Whether the treatment by the treating doctor is medically appropriate, b. Whether the injured employee is receiving appropriate medical care to reach maximum medical improvement, c. Whether medical care is in compliance with the EBG and any network protocols, d. Whether a conflict exists between the injured employee and the current treating doctor to the extent that the doctor-patient relationship is jeopardized or impaired, e. Whether the injured employee has recently received a release to Return to Work from the current treating doctor, f. Whether the reason for the change is to locate a treating doctor that would agree with surgery, or g. Other issues that are presented in a specific case-by-case review. 13 Revised

14 Process 1. In order to request a change to a third treating doctor (after the initial and alternate choices have been exhausted), the injured employee may look at the provider list at to review possible treating doctors. The injured employee can contact the network by: a. Phone: b. netcare@injurymanagement.com c. Fax: d. Mail: Copy of Change of Treating Doctor Form to: IMO Med-Select Network P.O. Box Carrollton, TX There are special circumstances when an injured employee may change to another treating doctor at any time. Those special circumstances are as follows: a. The injured employee moves to a location outside of the service area, or b. The current treating doctor dies, retires, or leaves the network. 3. When an injured employee contacts the network requesting a change of treating doctor, the network staff will determine if the injured employee has previously changed treating doctors and, if so, how many times he or she has changed doctors. 4. When appropriate, the staff member will explain to the injured employee: a. The difference between a change in treating doctor and a referral made by the current treating doctor, and b. The difference between the procedure to change from an initial treating doctor to an alternate treating doctor and the procedure to change from an alternate treating doctor to a subsequent treating doctor. 5. The network staff member will explain to the injured employee that the Change of Treating Doctor form is located on the IMO website at If the injured employee does not have internet access, a paper copy will be sent by mail or fax to the injured employee. The injured employee may ask the doctor s office to assist in completion of the form. 6. If the injured employee must change to a different treating doctor immediately, the staff member will complete the form and mail or fax a copy to the injured employee for signature. 7. If the change is from the initial treating doctor to an alternate treating doctor, the network staff will send the change approval to the two doctors, the injured employee, and the insurance carrier. 8. If the change is from an alternate treating doctor to a subsequent treating doctor, the network staff will use the criteria listed in this section of the Provider Manual to assist in determining if the change will be approved. Once the decision has been made, the network staff will contact the doctors, the injured employee, and the insurance carrier. If the request for change to a subsequent treating doctor is denied, the injured employee will also receive information explaining the appeal process. 14 Revised

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17 Selection of a Specialist as a Treating Doctor 1. An injured employee with a chronic, life-threatening injury or chronic pain related to a compensable injury may apply to the network s Medical Director to use a non-primary care physician specialist that is in the network as the injured employee treating doctor. 2. Unless there is an urgent medical need, an injured employee must complete the IMO Med- Select Form named Specialist as Treating Doctor as part of the process to request a change to a specialist as the treating doctor. The injured employee may need to obtain the doctor s assistance to complete the form and submit medical documentation explaining the need for a specialist as the treating doctor. The medical director will review the information to determine whether the request will be approved and may contact the proposed specialist and/or the injured employee as part of the review. 3. If there is an urgent medical need, the network will contact the Medical Director with the information. The medical director will discuss the nature of the illness or injury with the physician specialist to ascertain the urgency of the need for the specialist to become the treating doctor. If the medical director considers the need urgent, the medical director can approve the change prior to completion of the above named form. 4. Within seven days of receipt of the request form and any other information, a letter will be sent to the injured employee, the physician specialist and the carrier, explaining the medical director s decision. The letter will also explain the appeal process in case the injured employee does not agree with the decision. 17 Revised

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19 Out-of-Network Specialists 1. If a treating doctor decides that there is no provider or facility in the network that can provide the treatment his or her patient needs for treatment of the compensable injury, the treating doctor (or staff) will contact the network for permission to send the injured employee to a provider outside-of-network. 2. The treating doctor will submit a referral form Request for Out-of-Network Specialist explaining the diagnosis, the treatment requested, and the rationale for the use of an outof- network provider and medical necessity for the out-of- network treatment. 3. Upon receipt of the referral form, the network staff will review it for completeness and determine if there is a suitable network provider or facility. A network case manager or preauthorization nurse will review the completed referral. Assistance from the Medical Director may be requested. 4. The network will approve or deny the referral request within seven days of receipt from the treating doctor. If the circumstances or the condition of the injured employee require expedited approval, the network will approve or deny the referral within two days. 5. If emergency care is needed, the injured employee should proceed in the most expeditious manner to the nearest possible provider or facility to receive necessary care. 6. If the network denies the referral request, the treating doctor and injured employee will be notified by telephone and in writing. At the time of notification, the network will also explain that the injured employee may appeal the decision through the network s complaint process if the reason for the denial is something other than lack of medical necessity. 7. If the network denies the referral because it is not medically necessary, the notification will explain that the employee may file a request for an Independent Review as described in this Provider Manual and more thoroughly in 28 TAC Revised

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21 Preauthorization 1. Emergency care never requires preauthorization. 2. Emergency Admission: Notification to the network of the hospital admission, and any request for preauthorization for continuation of the inpatient stay, should occur as soon as the injured employee is stabilized. The preauthorization process will proceed with review of the length of stay. 3. Frequency of concurrent review for a continued length of stay is dependent upon the approved length of stay. The network would not anticipate a concurrent review every day. 4. Initial evaluations for physical therapy or occupational therapy do not require preauthorization. 5. Initial psychological evaluations do not require preauthorization. 6. Evidence Based Guidelines: Network providers are contractually obligated to follow the Evidence Based Guidelines such as Official Disability Guideline (ODG), American College of Occupational and Environmental Medicine (ACOEM) and Medical Disability Guidelines (MDG). Any treatment, service, or durable medical equipment that falls outside of, or is not recommended by, the ODG requires preauthorization prior to providing the treatment or service in order to receive reimbursement. The ODG should be consulted and used as medical evidence prior to requesting preauthorization. 7. Return to Work Programs: When requesting preauthorization for a return to work program (such as work hardening), describe the specific job to which the injured employee will return and include a treatment plan of care specific to that job description. All return to work programs must be preauthorized, including programs accredited by the Commission for Accreditation of Rehabilitation Facilities (CARF). 8. Process: a. The provider should submit a request for preauthorization or concurrent review by using the IMO Preauthorization Form. A general copy is provided in this manual and is also available for download on the IMO website at Fax the completed form listed on the client preference card or submit via the online version. b. If there has been an emergency admission to a facility, the request for a continued length of stay should be submitted within one business day of the admission. c. A request for preauthorization must include: The specific health care, with frequency and duration of treatments Medical information to support the medical necessity Phone, fax and contact information for the requestor Name of provider and facility Estimated date of care 21 Revised

22 d. An IMO nurse will review the request and submitted medical records. It is very important to submit information that will assist the nurse in the review, including any citations to the ODG or EBG. e. The nurse may approve the request but is not allowed by statute to disapprove a treatment or service. If the nurse is unable to approve the request based on the nurse s knowledge and the submitted information, the request and submitted medical records are referred to a physician or other appropriate provider for review and decision. f. If the reviewing physician has tentatively decided to disapprove the services, the physician will give the requestor a chance to discuss the clinical basis for denial. g. Decision: i. Within three business days of receipt of a completed preauthorization request, the network will contact the physician or physician s office to provide an approval or disapproval of services. ii. If a facility requests additional inpatient days for an injured employee, the network will contact the facility within twenty-four hours of the request. This contact may be by phone. iii. If the approval or denial was provided verbally, within one business day the network will send a letter confirming the approval or denial to the requestor, the injured employee, and the employee s representative, if any. h. Basis of Decision: The basis of approval or denial will be the medical necessity of the requested treatment or service. The preauthorization decision is not based upon the following issues: i. Unresolved compensability (for example, did it happen at work?) ii. Extent of injury or relatedness issues (for example, is the shoulder pain part of the compensable injury?) iii. Carrier liability for injury (for example, did the employer have workers compensation coverage at the time of this injury? iv. Maximum medical improvement (for example, a previous physician has said that the injury is completely healed). i. The network does not make decisions regarding compensability of the injury, the extent of the injury, relatedness, and/or carrier liability. The carrier or third party administrator handling the workers compensation claim will notify the network of any disputes regarding these issues. Information regarding any such disputes will be added to the preauthorization approval notification. j. If the network initially denies the request for preauthorization, the provider may request reconsideration of the preauthorization request. The request for reconsideration must be submitted within 30 days of the date the network issues a written initial denial of preauthorization. k. The network will respond to most requests for reconsideration within five days of receipt. The network will respond within three days to a reconsideration request for 22 Revised

23 concurrent review. The network will respond within one day to a reconsideration request for continued length of stay in a facility. l. If the network denies the preauthorization reconsideration, the notification will include information about how to request for an Independent Review as described in this Provider Manual and more thoroughly in 28 TAC m. The network also has an expedited process when there is an urgent medical need. The network will handle these cases in no longer than one day. If needed, call the network at or Preauthorization List: 1. Emergency care never requires preauthorization. 2. Initial evaluation for physical therapy and occupational therapy does not require preauthorization. Providers Responsibilities 1. IMO Med-Select Network providers are contractually required to follow Evidence Based Guidelines. 2. If the requestor is not the Treating Doctor, the Treating Doctor must be informed of the treatments and/or services that will be requested. 3. Notification is required for all therapy, diagnostic procedures and referrals to specialist. As the treating physician and/or facility, you are required to notify IMO of the referral for these services before the referral commences. If IMO did not receive notification before referral was commenced, including a physical therapy evaluation, IMO may deny the bills under review code B5 (coverage/program guidelines were not met). This notification does not replace the Network Preauthorization process. 4. To ensure services are provided by network providers, Network Notification is required for all therapy, diagnostic procedures and referrals to specialist. This notification does not replace the network preauthorization process. 5. Upon requesting a return to work program (such as work hardening), the specific job the injured employee will return to and the description should be included with the request, in addition to a treatment plan of care specific to that job and description. IMO Network Preauthorization List 1. Hospital and Surgical Care a. All inpatient admissions including length of stay and, when necessary, extending the authorized length of stay b. All inpatient and outpatient surgical procedures performed in hospital or Ambulatory Surgical Center (ASC) 2. Mental Health Care a. All psychological/psychiatric services after the completion of the initial evaluation. 23 Revised

24 3. Physical Medicine Services (regardless of location) a. Osteopathic or chiropractic manipulations after the first six sessions occurring within 30 days following the initial treatment date. b. Physical or occupational therapy outside of the first six sessions occurring within 30 days following the initial treatment date or up to 12 sessions occurring within 60 days following surgical intervention 4. Diagnostic Testing a. CT myelograms and discogram CTs b. Repeat Diagnostics 5. Injections a. Epidural Steroid Injections (ESIs) and facet injections b. Medial branch blocks and rhizotomies 6. Rehabilitation Programs a. Work hardening, work conditioning, and outpatient rehabilitation regardless of accreditation b. Pain management, chemical dependency and weight loss 7. Durable Medical Equipment (DME): Billed at $1,000 or greater per item, either cumulative rental or purchased. All electrical and/or neuromuscular stimulators including transcutaneous electrical stimulators (TENS) or interferential stimulators 8. Treatment not addressed or not recommended by Evidence Based Guidelines: Unless preapproved as part of a treatment plan 9. Drugs identified with a status of N in the current edition of the Official Disability Guidelines Treatment in Workers Compensation (ODG)/Appendix A, the ODG Workers Compensation Drug Formulary and any updates and any compound that contains such a drug 24 Revised

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26 Compensability of the Injury 1. In Workers Compensation, there may be questions and disputes regarding numerous issues. One issue may be whether the injury happened at work (you may hear the term in the course and scope of employment ). This is usually when a provider may hear the carrier state the injury is noncompensable. There are specific time frames for the carrier to meet regarding denial of compensability. 2. Other examples of disputes include: 1) whether a specific insurance carrier has liability for the claim and 2) whether a specific diagnosis is related to the injury (this could be an issue of extent of injury or relatedness ). 3. In the network setting, the carrier may be liable for up to $7,000 of medically necessary health care costs even if the claim is found to be non-compensable. If a carrier contests compensability of the injury, a carrier must notify, in writing, any network provider who has treated the patient. 4. A carrier may not deny payment for services provided prior to the notification on the grounds that the injury was not compensable. In addition, if the provider has received payment prior to the written notification, the carrier cannot request a refund of those payments based on noncompensability. This requirement is addressed in Section (e) of the Texas Insurance Code. 5. No specific diagnoses are excluded from being covered under workers compensation insurance, but potentially any diagnosis could be excluded as it relates to compensability. In other words, even if a carrier agrees that an injury occurred within the course and scope of employment, which does not necessarily mean that, the carrier will agree that the employee s current diagnosis is related to that injury. The carrier, not the network, decides if they will dispute the compensability of the claim or the causal connection between the compensable injury and the current diagnosis. Medical Bill Submission and Payment 1. The network does not pay the medical bills submitted for reimbursement. The medical bills should be addressed to the appropriate insurance carrier, third party administrator, or certified self insured employer handling the compensable claim. 2. All requirements, including forms to submit and time frames for billing and payment, follow the administrative rules of the Division of Workers Compensation. These can found in Chapter 133 of 28 Texas Administrative Code. 3. The reimbursement amount may differ from the fee guidelines adopted by the Division of Workers Compensation because the network negotiates and signs a contract with every provider or provider group. The contract spells out the amount of reimbursement the provider will receive. 4. Providers must submit their bill no later than 95th day after the date of service. Texas Labor Code (a) states, "Failure by the health care provider to timely submit a claim for payment constitutes a forfeiture of the provider's right to reimbursement for that claim." 26 Revised

27 5. The 95-day requirement is extended if the provider bills the wrong workers compensation insurance carrier or believes that the injury is not a work injury and bills the general health insurance carrier. In that case, the 95-day period begins at the time that the provider knows that he or she billed the insurance carrier. The provider may have to show proof of submission to the wrong carrier. 6. If the carrier or the network requests additional documentation regarding the medical service, the provider must submit additional documentation, or send a notice that there is no additional documentation, within 15 days of receiving the request. 7. You are to be paid within 45 days of submitting a complete bill. The requirements of a complete bill can be found in the Chapter 133 rules (28 Texas Administrative Code Chapter 133) and instructions for completion of a medical bill are on the Division of Workers Compensation website ( The network can decide to perform an on-site audit. If it does, a portion of your bill will be paid within 45 days of receipt. 8. Along with your payment, you will receive an Explanation of Benefits (EOB). The format of the EOB is also mandated by the Division of Workers Compensation rules and instructions. Under some circumstances, the insurance carrier or the network is required to send an EOB to the injured employee. Those circumstances include denial of payment because the health care was: a. Determined to be medically unreasonable or unnecessary; b. Provided by a doctor other than: 1) the treating doctor or treating doctor s referral or 2) a doctor performing a required medical exam or a designated doctor exam; c. Unrelated to compensable injury. 9. If you are dissatisfied with your reimbursement, you can request reconsideration. The request for reconsideration must be no submitted later than 10 months from date of service in question. You cannot request reconsideration until: a. The carrier has taken final action, or b. You have not received an EOB within 50 days of submitting your bill. 10. If you request reconsideration, you should: a. Reference the original bill and include the same billing codes, date(s) of service, and dollar amounts as the original bill; b. Include a copy of original EOB or, if none was received, a copy of the request for an EOB; c. Include any necessary documentation not submitted originally to support your position; and d. Give a bill-specific, substantive explanation and rationale to modify the previous denial or payment. 11. The carrier or the network must act on the request for reconsideration within 31 days of receipt of a complete request. 12. If you are still dissatisfied with the decision, you may request dispute resolution. Fee disputes are handled by the network. Medical Necessity disputes are handled by the Texas Department of Insurance through the Independent Review Organization (explained later in this Provider Manual). 27 Revised

28 Complaints and Fee Disputes 1. If you are dissatisfied with any part of the network, you can file a complaint with it. Any complaint must be filed within 90 days of the event about which you are dissatisfied. 2. You may file a complaint regarding dissatisfaction with any aspect of the network s operations. A complaint does not include: a. A misunderstanding or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction; or b. An oral or written expression of dissatisfaction or disagreement with an adverse determination. 3. You can contact the network by: a. Writing: P.O. Box Carrollton, TX b. Calling: c. ing: netcomplaint@injurymanagement.com 4. Each provider in the network is required to post a notice to injured employees on the process for resolving complaints with network in their office. This notice will include the contact information for filing complaints directly with the network. It will also include the following Texas Department of Insurance (TDI) contact information regarding filing a complaint directly with TDI: a. Toll free number: b. Address: HWCN Division, Mail Code 103-6A, Texas Department of Insurance, P. O. Box , Austin, Texas c. Website: 5. A complaint may be filed by: a. An employee, b. An employer, c. A health care provider, or d. Another person designated to act on behalf of the employee. 6. The network will not retaliate against anyone who files a complaint against the network or appeals a decision of the network. 7. The network will respond to a complaint within seven calendar days after receipt. The response shall include an acknowledgment of network s receipt of the complaint, an acknowledgement of the date of receipt, and a description of network s complaint and appeal procedures and deadlines. 8. Every specific complaint will be investigated and resolved no later than 30 calendar days after receipt by the network. A resolution letter will be sent to you explaining the resolution of the complaint. 9. An appeal of the network s resolution must be filed within 15 days of the complainant s receipt of the resolution letter. 28 Revised