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.

Preauthorization  

If you’re a provider who needs preauthorization for non-emergency healthcare services or treatment, please follow these steps: 

1. Review the list of treatments requiring approval before providing care: 
   • Treatments requiring approval for Alliance providers
   • Treatments requiring approval for non-Alliance Providers 
2. Complete the appropriate request form: 
   • Preauthorization for health care services
   • Preauthorization for prescription drugs 
3. Fax the request form with supporting clinical documentation to 888-777-8272. 

Questions? Call 800-482-7276. 

Treatment guidelines  

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.

Medical billing 

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: 

TASB 
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. 

Pharmacy Billing 

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: 

TASB 
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. 

Billing tips 

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. 

Helpful resources 

Here are some links to information and forms that may be helpful: 

• DWC Forms: DWC 60, 66, 67, 68, 69, 73 
• Centers for Medicare & Medicaid Services 
• Texas Department of Insurance, Division of Workers' Compensation 
• The pharmacy rules: 134.500 - 134.540 
• TDI-DWC: Pharmacy Closed Formulary