WORKLINK PROVIDER MANUAL TABLE OF CONTENTS D. PRE-AUTHORIZATION PROVIDER RECONSIDERATION PROCEDURES P.4

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1 WORKLINK PROVIDER MANUAL TABLE OF CONTENTS A. INTRODUCTION LETTER P.2 B. PROVIDER INFORMATION SHEET P.3 C. BILL PROCESSING & CLAIMS FILE INFORMATION P.3 D. PRE-AUTHORIZATION PROVIDER RECONSIDERATION PROCEDURES P.4 E. PRE-AUTHORIZATION REQUEST FORM GUIDELINES P.6 F. PRE-AUTHORIZATION STATUS P.8 G. PRE-AUTHORIZATION LIST P.9 H. PRE-AUTHORIZATION REQUEST FORM P.10 1

2 Dear Provider, The following information is provided to you as a guide to the processes and procedures for your participation in Memorial Herman Health Solutions, Inc WorkLink Occupational Medicine PPO Network. As part of the WorkLink Occupational Medicine Network, we value your partnership highly and look forward to a strong relationship. Our mutual goal is to return the injured employee to work at the proper time through appropriate care and timely, well documented communication among all parties. Our clients employees benefit by receiving high-quality, efficient, convenient care. Our goal is to maintain a network of physicians experienced in successfully managing employees with occupational injuries in ways which benefit the employee, employer and physician. You are a valuable part of this network, and we want to be a valuable part of your practice. As part of the WorkLink Occupational Medicine PPO Network, our agreement with our employer clients is to have all of our providers paid within 45 days and to utilize our physician network exclusively. This ensures prompt payment for services and directs injured workers to your practice. We have a 72-hour turnaround time for all preauthorization requests, and will always strive to provide you with any necessary information as quickly and efficiently as possible. Our goal is to attract and retain the best qualified physicians as part of our Occupational Medicine Network. We are aware that our goal only can be reached by choosing our partners carefully. Unlike many of our competitors, we do not seek to have the largest network by inviting everyone to be a member. You have been selected because we value your expertise. The following pages are provided to assist you and your staff with information regarding our processes and forms. This manual along with all forms can be provided to your office electronically. Congratulations on becoming part of the Memorial Herman Health Solutions, Inc WorkLink Occupational Medicine Network that treats injured employees in our community. If you have any questions, please don t hesitate to contact us. Sincerely, The Memorial Herman Health Solutions WorkLink Team

3 WORKLINK PROVIDER INFORMATION SHEET Memorial Herman Health Solutions, Inc wishes to welcome you to the WorkLink Occupational Medicine Plan. We hope you will find the information provided on this handout both informative and helpful. If you have any questions, would like this sent to you electronically or wish further information related to this Plan, please contact us at: Main Line Phone Numbers or toll free Medical Case Management Option # 3 Address: WorkLink@memorialherman.org Fax: Pre-Authorization Department Toll free Option #2 or Option # 2 Address: WorkLink@memorialherman.org Fax: Fax Customer Service Option # 4 Address: WorkLinkCS@memorialherman.org Fax: Bill status, Billing information and Provider Network Information E-Billing Payor ID# 3 CB026 Clearinghouse Workcomp EDI Bill Processing Bills should include: Claim number, injured worker name, social security number and date of birth. WorkLink will process all clean claims within 30 days of receipt of the claim. After approval by the employer for payment, bills are submitted to WorkLink for processing. **IMPORTANT CLAIMS FILING INFORMATION** Unless otherwise instructed, all bills should be directed to the employer of the injured worker being treated. Should you have any questions regarding billing, please contact the WorkLink offices directly and we can assist you in routing the bills to the appropriate employer. Mailing Address Memorial Herman Health Solutions Inc. WorkLink 7737 Southwest Freeway, Suite C-99 Houston, Texas 77074

4 PRE-AUTHORIZATION PROVIDER RECONSIDERATION PROCEDURES An overview of WorkLink s Reconsideration Process is as follows: The Importance of Reconsiderations Procedures In the work injury setting, certain healthcare services require authorization either by WorkLink or the employer. An important aspect of the WorkLink Utilization Review function is to encourage contracted providers to practice cost-efficient medicine and to provide quality care for injured workers. Such a process involves mutual collaboration between healthcare providers so as to best determine if healthcare services are medically appropriate for the injured worker. The courts have recognized that the treating physician has a duty to determine, based upon medical judgment, those treatment options that will aid in the diagnosis, treatment and medical management of injured workers. It becomes the legal duty of the physician to communicate any disagreements in a treatment decision to WorkLink or any other third party that has denied services if the physician feels the injured worker will be at risk from that decision. Who Can Initiate the Reconsideration Process An injured worker, treating physician, or a person acting on behalf of a member may request an reconsideration of an adverse Utilization Review (UR) determination, either orally or in writing. When to Utilize the Reconsiderations Process If a request for medical or surgical services has not been authorized or is denied by WorkLink during the Preauthorization process, the treating physician should initiate a reconsideration on behalf of the injured worker if in his / her judgment the lack of authorization could pose potential harm or injury to a injured worker. A healthcare provider may also initiate a reconsideration on behalf of a member when an adverse determination has been rendered for hospitalized injured workers on the basis of continued stay non-certification. WorkLink recommends that our contracted providers utilize the reconsideration process when: a. WorkLink s Medical Director proposes alterations in the treatment plan which the treating physician feels are not indicated, unnecessary or not in the injured worker s best interest. b. WorkLink has denied payment of healthcare claims on the basis of failure to obtain preauthorization of services, but the provider feels that the services were medically necessary. c. The pre-authorization process has not been timely, or there are other problems with the medical care management process that may affect the injured worker adversely. 4

5 How to File A Reconsideration An injured worker, treating physician or a person acting on behalf of the injured worker may file a reconsideration by notifying WorkLink s Pre-authorization Department at or Option 2. All reconsideration requests must be submitted in writing and may be faxed or mailed directly to WorkLink at: About WorkLink s Reconsiderations Process WorkLink Attn: Pre-authorization Reconsiderations Dept Southwest Freeway, Suite C-99 Houston, Texas WorkLink has established two types of Reconsiderations processes. One process is for Expedited Reconsiderations, which is carried out for emergent care services or life threatening medical conditions for which an adverse determination has been issued. The second process is for Routine Reconsiderations, or nonemergent requests (for example, scheduled surgery, scheduled admissions or retroactive claims denials). 5

6 Requestor Information PRE-AUTHORIZATION REQUEST FORM GUIDELINES This section is to be completed by the provider initiating the request. 1. Date of Request: Insert the date the request for authorization is made 2. Person Completing Request: Enter the name of the person completing the requested information 3. Type of Request: Check the appropriate box of who is requesting authorization of services. Please indicate if the provider disagrees with the medical necessity of a injured worker s requested services. 4. Provider Tax Identification Number: Enter the providers billing tax identification number 5. Phone Number/Fax Number: Enter provider s call back telephone number and fax number. Injured worker Information 1. Injured worker Name: Enter the full name, including any middle initials of the injured worker 2. Date of Birth: Enter the date of birth of the injured worker. 3. Age: Enter the age of the injured worker. 4. Sex: Enter the sex of the injured worker Requested Services The following sections are to be completed as applicable to pre-authorize services. Please refer to the Preauthorization List for those services that require authorization. 1. Start Date: Enter the date services should begin 2. End Date: Enter the date services are expected to end if known 3. CPT/ICD-9 Codes: Completion of diagnosis and procedure codes is optional; however, WorkLink reserves the right to request those codes if the level, extent or type of services requested is not clear. 4. Inpatient Admissions: Pre-authorization required for all non-emergency admissions. 5. Inpatient Rehabilitation/Skilled Nursing Facility (SNF): If the injured worker is currently an outpatient at the time services are requested, authorization for inpatient rehabilitation/snf is to be obtained by the requesting physician. WorkLink reserves the right to initially authorize an evaluation only to determine whether the injured worker meets criteria for rehabilitation or SNF services based on the health plan benefit requirements and/or to determine the rehabilitation potential and/or skilled SNF needs of the injured worker for appropriate placement. If the injured worker is currently a inpatient at an acute care facility, authorization for inpatient rehabilitation/snf is to be obtained by the admitting facility after inpatient rehabilitation or SNF evaluation has been conducted. WorkLink will work with hospital discharge planning staff to determine the facility to 6

7 be utilized, and will take into consideration the needs and desires of the injured worker as well as the capabilities of the contracted facility to adequately meet the needs of the injured worker. 6. Surgery/Medical Procedure: If the injured worker is to have a surgery or other medical procedure, please note the name of the procedure. Please denote if the surgery/medical procedure will be inpatient (I/P) or outpatient (O/P) by checking the appropriate box. Then proceed to Section VI and note the name of the facility where the surgery/medical procedure will be performed. Then proceed to Section VIII and complete the indications. The hospital s abbreviations may be used for surgeries/medical procedures to be scheduled at Memorial Hermann Hospital System facilities. 7. Imaging/Invasive Diagnostic Procedures: For procedures requiring authorization, please note the name of the procedure(s) in the blank space below this section. NOTE: If multiple procedures are requested for the same date of service to support a diagnostic impression, WorkLink s Medical Director may recommend one primary procedure based on the Occupational Disabilities Guideline, unless the treating physician can substantiate the clinical rationale for requesting multiple procedures. 8. Durable Medical Equipment (DME)/Prosthetics: If the injured worker is an outpatient at the time services are requested, authorization for DME/prosthetics is to be initiated by the requesting physician in order to determine if the injured worker meets DME/prosthetic criteria. If the injured worker is an inpatient at an acute care facility at the time services are requested, authorization for DME/prosthetics is to be obtained by the inpatient facility s discharge planner or case manager in order for WorkLink to determine whether the injured worker s injury meets DME/prosthetic criteria. WorkLink reserves the right to authorize either rental or purchase, depending upon the type of DME and the length of time the DME may be needed. WorkLink will provide the name of contracted vendors to be utilized. 9. Outpatient Rehabilitation: please circle the type of O/P rehabilitation (PT, OT, Speech) service requested; WorkLink reserves the right to initially authorize an evaluation only to determine whether the injured worker meets criteria for rehabilitation 10. Other: If there are other requested services not addressed by the Official Disabilities Guidelines (ODG) and not specifically delineated above, please enter the request in this area. Location of Services In this section, note the name and location of the facility where the Requested Services will be rendered. WorkLink will make authorization considerations based on whether the requested facility is a contracted provider for the services to be provided, and/or if the facility has the capabilities to appropriately meet the needs of the injured worker. 7

8 Injured Worker Clinical Information All requests for authorization require clinical information about the injured worker. This information is needed to appropriately render a determination of medical necessity. Instructions are as follows: 1. Primary Diagnosis: Please note the injured worker s primary diagnosis. 2. Secondary Diagnosis: Please note any of the injured worker s contributory secondary diagnoses. 3. Medical History: Please provide WorkLink with a brief history of the injured worker, as may be pertinent to the injured worker s primary/secondary diagnoses and other history pertinent to the requested service. 4. Injured worker s Special Needs: Please provide any special needs or circumstances of the injured worker, including any disabilities the injured worker may have. Special needs may include medical related, as well as psycho-social. WorkLink will consider special needs of the injured worker when making authorization determinations. 5. Supporting Clinical Information: This section is to be completed for all Requested Services. The purpose of this section is to alert us to additional tests/clinical findings about the injured worker and treatment that has been rendered to date, as may be applicable to the particular requested service. Please document any applicable test findings, symptoms, duration of illness, etc. as may be appropriate to the requested service. Pre-Authorization Status This section is to be completed by WorkLink s Pre-Authorization Department. WorkLink s Pre-Authorization t Department will notify the requesting provider by phone or fax a copy of the Pre-Authorization approval/denial letter within 72 hours of receipt of request. WorkLink s Pre-Authorization Department will utilize the Official Disabilities Guidelines (ODG) or other nationally recognized criteria to approve or deny the medical necessity of the requested service. An overview of this section is described as follows: 1. Date of Initial Determination: WorkLink will enter the date a determination was rendered. 2. Authorized: WorkLink will check the Authorized box if the requested services are approved as medically necessary. 3. Authorized with Modification: In certain instances, WorkLink may authorize the initial request with modifications made in the scope, level, extent and/or location of services. For example, a particular surgery was requested to be performed inpatient when the injured worker meets criteria for an out surgery. WorkLink will note any modifications in writing in this section of the form. 4. Denials/Rationale: WorkLink s Medical Director will issue an initial pre-authorization denial with the rationale for this denial sent to the provider via a written Preliminary Notice of Adverse Determination. The provider may contact WorkLink directly to discuss this with the WorkLink Medical Director prior to the final determination being rendered. 5. Assigned Authorization Number: WorkLink will assign an authorization number for internal tracking and to facilitate billing. Please note this authorization number is not a guarantee of payment. Final claim 8

9 determination will be made in writing following receipt and review of the claim. Please reference the authorization number on the claim. 6. Authorized By: A WorkLink Utilization Review (UR) nurse issuing the authorization will sign this section along with the physician reviewer s name, if the review was conducted by a physician as in the case of a denied or authorization with modification determination. Please fax completed Pre-authorization Request Form to: WorkLink Pre-authorization Department or Toll Free Please direct all questions to: Option 2 or Toll Free Pre-Authorization List (1) Inpatient hospital admissions including the principal scheduled procedure(s) and the length of stay; (2) Outpatient surgical or ambulatory surgical services, as defined in subsection (a) of this section; (3) Spinal surgery, as provided by Texas Labor Code ; (4) Psychological testing and psychotherapy, repeat interviews, and biofeedback; except when any service is part of a preauthorized or exempt rehabilitation program; (5) External and implantable bone growth stimulators; (6) Chemonucleolysis; (7) Myelograms, discograms, or surface electromyograms; (8) Unless otherwise specified, repeat individual diagnostic study, with a greater than $350 or documentation of procedure (DOP). (Diagnostic study is defined as any test used to help establish or exclude the presence of disease/injury in symptomatic persons; the test can help determine the diagnosis, screen for specific diseases/injury, guide the management of an established disease/injury and help formulate a prognosis); (9) Work hardening and work conditioning services (10) Rehabilitation programs to include: (A) Outpatient medical rehabilitation; and (B) Chronic pain management/interdisciplinary pain rehabilitation; (11) Durable medical equipment (DME) in excess of $500 per item (either purchase or expected cumulative rental) and all transcutaneous electrical nerve stimulators (TENS) units; (12) Nursing home, convalescent, residential, and all home health care services and treatments; (13) Chemical dependency or weight loss programs; and (14) Investigational or experimental service or device for which there is early, developing scientific or clinical evidence demonstrating the potential efficacy of the treatment, service, or device but that is not yet broadly accepted as the prevailing standard of care. (15) Second Surgical Opinions (16) Physical Therapy post 6 weeks of injury. All non-surgical cases past three weeks of physical therapy or physical therapy requests exceeding 3 times per week, should require pre-authorization to ensure the proper utilization guidelines are followed 9

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11 Pre-Authorization Request Form Memorial Herman Health Solutions WorkLink 7737 Southwest Freeway, Suite C-99 Houston, Texas Phone: Option 2 I. REQUESTOR INFORMATION Pre-Authorization Request Pre-Authorization Reconsideration Date of Person Completing Type of Request Phone Request Request Physician Office Facility mo day year Other Fax Name of Ordering Physician: Tax ID # III. INJURED WORKER INFORMATION Injured worker Name: (Last/First/MI) Date of Birth Age / / Employer Insurance Carrier: Claim No: Sex Male Female V. REQUESTED SERVICES BY CPT CODE VI. SERVICE DETAILS Facility/Vendor: Provider: Phone: Fax: Address: Date of Service: VII. CLINICAL INFORMATION (Fax clinical to or toll free at ) Primary Diagnosis: Secondary Diagnosis: Medical History: ICD-9 Code: ICD-9 Code: Supporting Clinical information for requested service: (Describe applicable symptoms, illness duration, pertinent test, treatment) Is this injured worker disabled (outside the work related injury) and/or have any special needs or circumstances? yes no (please explain if yes) **This authorization does not guarantee payment. Final claim determination will be made in writing following receipt and review of the claim and verification of compensability. This information is Privileged & Confidential and is intended for use only by the individuals or entities named on this form. If the reader of this form is not the intended recipient or person responsible for delivering it to the intended recipient, the reader is hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If this communication is received in error, the reader shall notify sender immediately and shall destroy all information received. 11