What treatment services require pre-authorization?

by Kara Dolan-West | Mar 06, 2019 | Workers' Compensation

The BWC’s MCO standardized prior authorization table

Service Prior Authorization Required  No Prior Authorization Required
Physical medicine services, including chiropractic/osteopathic manipulative treatment and acupuncture Yes
Psychological services Yes
Dental Yes
Evaluation and management services Yes for psychological consults or chronic pain program consults All other evaluation and management services
Diagnostic testing Yes. For drug test, please refer to the “Drug Testing” policy. Basic X-rays
Durable Medical Equipment (DME) Yes, if purchase price is equal or greater than $250

Yes, for DME rentals anticipated to or having the probability to exceed 80 percent of the purchase price of the DME

For DME, please refer to the “Durable Medical Equipment” policy.

DME purchase price is less than $250
Home/Vehicle modifications Yes. For home/vehicle modifications, please refer to the “Home and Vehicle Modifications” policy.
Home health agency services Yes
All inpatient and outpatient hospital services treatment and ambulatory surgery center services Yes, unless for emergency services. Emergency inpatient hospitalization may be through the emergency department or by direct admission
In-home physician services Yes, after first visit

For in-home physician services, please refer to the “In-home Physician Visits and Physician Mobile Office Visits” policy.

First visit
Injections Yes
Non-emergency ambulance (medical transportation) services Yes
Orthotic Yes, if greater than $250
Prosthetic or artificial appliance and/or repair Yes, if greater than $250

For prosthetic or artificial appliance and/or repair, please refer to the “Artificial Appliance Requests” policy.

Skilled nursing facility (SNF)/Extended care facility (ECF) Yes
TENS and NMES units Yes, for both rental and purchase

For TENS and NMES units, please refer to the “TENS and NMES” policy.

TENS and NMES monthly supplies Yes, with a maximum of six months per authorization

For TENS and NMES units, please refer to the “TENS and NMES” policy.

Vision and hearing services Yes, if greater than $100 Vision and hearing services less than or equal to $100
Vocational rehabilitation – all vocational rehabilitation services, in or out of plan Yes, unless meets the “NoPA Required” criteria

For vocational rehabilitation, please refer to the vocational rehabilitation policies (click here).

Transitional work on-site therapy services provided by an occupational therapist that fall under the presumptive authorization criteria

Note: Occupational rehabilitation/Comprehensive (work hardening) requires CARF

This means the requesting physician will need to submit a C9 requesting the listed treatments before payment of those treatments will be considered.

For questions or concerns, please contact our office at 614-545-9990.

Tags: authorization BWC physician services treatment Workers' Compensation