Non-Emergency Treatments Requiring Preauthorization
Find out which non-emergency healthcare treatment requests must be approved before care is rendered — broken down by Alliance and non-Alliance members, and learn how to submit preauthorization requests.
Some healthcare treatment requests must be approved before care is rendered. Examples include inpatient hospital admissions, including the principal scheduled procedure(s) and the length of stay; and outpatient surgical or ambulatory surgical services to the spine only, including all injections to the spine:
- The Alliance might occasionally modify the list of services requiring preauthorization. For a complete, current list, visit the Alliance website.
- This preauthorization list is not the same as the Division of Workers' Compensation preauthorization list (Administrative Rule 134.600).
- Post-stabilization treatment, and treatments and services for an emergency or life-threatening condition, do not require preauthorization.
The following non-emergency healthcare treatment requests must be approved before care is rendered:
- Inpatient hospital admissions
- Outpatient Surgical or ambulatory surgical services
- Spinal Surgery
- All non-exempted work hardening
- All non-exempted work conditioning
- Physical or occupational therapy except for the first six visits if those six visits were done within the first two weeks immediately following date of injury or date of surgery
- Any investigational or experimental service
- All psychological testing, psychotherapy, repeat interviews and biofeedback
- Repeat diagnostic studies greater than $350
- All durable medical equipment (DME) in excess of $500
- Chronic pain management and interdisciplinary pain rehabilitation
- Drugs not included in the TDI Division of Workers’ Compensation Formulary
- Any treatment or service that exceeds the Official Disability Guidelines
Request one of these treatments by calling 800-482-7276, x6654 or faxing the preauthorization form and supporting clinical documentation to 888-777-8272.
If a treatment or service request is denied, we will tell you in writing. This written notice will have information about your right to request a reconsideration or appeal of the denied treatment. It will also tell you about your right to request review by an Independent Review Organization through the Texas Department of Insurance.