What Healthcare Providers Need to Know
Healthcare providers prioritize taking care of injured employees, so our goal is to minimize paperwork needed to provide services and billing. This information is specifically for healthcare providers.
If you’re a provider who needs preauthorization for non-emergency healthcare services or treatment, please follow these steps:
- Review the list of treatments requiring approval before providing care:
- Complete the appropriate request form:
- Fax the request form with supporting clinical documentation to 888-777-8272.
Questions? Call 800-482-7276.
The Texas Department of Insurance has adopted the Official Disability Guidelines (ODG) for workers' compensation medical treatment in Texas. The ODG provides evidence-based guidelines to ensure appropriate treatment. The Division of Workers’ Compensation also requires MDGuidelines for disability management and return-to-work. Healthcare providers and payors are required to use both the ODG and MDGuidelines.
Billing for medical and pharmacy
The Fund works with two different companies to handle billing, which in most cases must be done via electronic submission. Here are some key steps to ensure bills are processed quickly. Remember, healthcare providers with fewer than 10 employees and for whom workers’ compensation represents less than 10% of their business are not required to submit electronically, though it is recommended.
For complete, current billing instructions for health care providers and hospitals, visit the Texas Department of Insurance general billing guide.
Please submit all billing documents to Mitchell, the company contracted by the Fund.
The preferred method for bill submission is electronic via WorkComp EDI. The Payer ID is WR902.
Medical bills may also be faxed directly to Mitchell at 732-212-7009 or mailed to the following address:
P.O. Box 2983
Clinton, IA 52733-2983
Please send billing documents directly to Mitchell. Any documents faxed or mailed to the Fund will be forwarded to Mitchell for processing.
To obtain bill status, contact Mitchell directly by calling 800-732-0153. You can also contact Mitchell by calling the main Fund line at 800-482-7276 and choosing Option 1, then Option 2. Their office is open from 7:30 a.m.–5:30 p.m. Central time.
The Fund contracts with Optum to process pharmacy bills.
The preferred method for bill submission is electronic via VitalPoint.
Pharmacy bills may also be faxed to the TASB office at 800-580-6720 or mailed to the following address:
P.O. Box 2010
Austin, TX 78768
Any documents faxed or mailed to the Fund will be forwarded to Optum for processing.
To check bill status, contact Optum by calling 855-241-0680 or emailing TPA-BillReview@optum.com.
Use the proper Division of Workers’ Compensation (DWC) billing forms and complete all required fields accurately:
- CMS-1500 for physician services and ambulatory surgical services.
- UB-04 for facility charges, including hospital, inpatient and outpatient services, and home health services
- DWC-66 for pharmacy services.
- Make sure the bill is complete per DWC Rule 133.1.
- Check DWC Rule 133.210 for documentation requirements.
- Submit bills within 95 days of the date of service.
- Provide a valid state medical license number and NPI number.
- Provide valid diagnosis codes (ICD-9 codes).
- Provide valid procedure codes (CPT codes).
- Provide valid NABP and FID numbers.
- Include modifiers for procedure codes when required.
- Include a physical address in Box 32 for ambulance bills.
Checking claim status
Call 800-482-7276 to see if we have a claim on file or to get a claim number. You will need the injured employee's full name and/or Social Security number.
HIPAA and workers’ compensation
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) does not apply to workers' compensation insurers, workers' compensation administrative agencies, or employers when disclosing protected health information (PHI) as required by state law for workers' compensation purposes.
State law requires workers' compensation system participants to disclose an injured employee’s protected health information (PHI) as necessary to process or adjudicate claims or to coordinate care under the workers' compensation system. System participants that make PHI disclosures to other workers' compensation participants as required by the DWC rules are, therefore, exempt from HIPAA rules regarding those disclosures.
For more information, see Advisory 2003-05 or the Texas Department of Insurance, Division of Workers’ Compensation downloadable document, HIPAA and Texas Workers' Compensation.
Here are some links to information and forms that may be helpful:
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Bona Fide Offer of Employment Template
When the doctor clears your injured employee to return to work, use this template to issue a bona fide offer of employment that meets state requirements.
Employee Acknowledgement of Alliance Direct Contracting Program
Employees must sign this form acknowledging they understand how to receive health care in the Political Subdivision Workers’ Compensation Alliance. Available in English and Spanish.
Employee Incident Investigation Worksheet
Uncover and correct the root causes of workplace accidents to reduce the risk of them happening again.