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At a Glance:
Title:
453-02-2258-m4
Date:
November 25, 2002
Status:
Medical Fees

453-02-2258-m4

November 25, 2002

DECISION AND ORDER

Summary

Positive Pain Management, Inc. (“Provider”) provided chronic pain management services to a claimant during the time when one preauthorization time period had expired and before another had begun. Three dates of services are in dispute. This decision finds that the total number of sessions did not exceed the number preauthorized, and there was no evidence showing that the claimant’s medical need for the treatment changed between the listed dates of preauthorization. Reimbursement for the three days of services at $1,080 a day under CPT code 97799-CP is ordered.

Discussion and Analysis

Crawford and Company, the utilization review agent for the Carrier, Transcontinental Insurance Company, preauthorized twenty visits and listed service dates of December 8, 2000, to January 8, 2001. Crawford and Company subsequently preauthorized ten additional visits with service dates from January 12, 2001 to January 29, 2001. The dates of service in question are January 9, 10, and 11, 2001. The only evidence submitted was the certified record and separate copies of the preauthorizations.

Because the three service dates were not specifically listed in the preauthorization, they should not be reimbursed, according to the Carrier. Because treatment did not exceed the number of visits preauthorized, the Provider argued that there was no overutilization and it should be paid.

Texas Workers’ Compensation Commission rule 28 Tex. Admin. Code §134.600 defines a provider’s and carrier’s role in the pre-authorization process. It requires preauthorization for chronic pain management before services are provided.

In this case, the twentieth day of service was not provided until January 12, 2001. Preauthorization for that number of treatments was given before the Provider rendered services. In addition, there was no evidence that the claimant’s medical condition changed during the few dates not covered by one of the two preauthorizations. It is reasonable to assume his medical needs did not change because the Carrier preauthorized ten more treatments after that time. Finally, the entire treatment span, December 11, 2000, through January 31, 2001, was a reasonably short time. Therefore, the Carrier should reimburse the Provider the amount due, $3,240 ($1,080 a day for three days).

Findings of Fact

  1. After a workers’ compensation claimant sustained a work-related injury, Positive Pain Management, Inc. requested preauthorization from the Carrier, Transcontinental Insurance Company.
  2. In its first preauthorization, the Carrier preauthorized twenty service dates, from December 8, 2002 to January 8, 2001.
  3. In its second preauthorization, the Carrier preauthorized ten additional dates of services, from January 12, 2001 to January 29, 2001.
  4. Three treatment dates, January 9, 10, and 11, 2001, fell between the two preauthorizations.
  5. After the Carrier denied payment for the three treatment dates at the rate of $1,080 per day, the Provider sought Medical Review Division review.
  6. The Medical Review Division officer granted the request and ordered the Carrier to pay the total amount due for treatment---$3,240.
  7. The Carrier timely appealed to the State Office of Administrative Hearings.
  8. Notice of the hearing was issued to all parties on March 27, 2002.
  9. The Commission’s Statement of Matters Asserted was filed on September 9, 2002.
  10. The hearing on the merits convened on September 25, 2002, and the Provider and Carrier were both represented at the hearing.
  11. The total number of chronic pain management treatments billed by the Provider under CPT code 97799-CP did not exceed the number preauthorized.
  12. Preauthorization for all treatments was granted before the treatment was provided.
  13. There was no evidence that the claimant’s medical needs changed during the few dates not covered by one of the two preauthorizations.
  14. The entire treatment span, December 11, 2000, through January 31, 2001, was a reasonably short time.

Conclusions of Law

  1. The State Office of Administrative Hearings has jurisdiction over matters related to the hearing, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann§413.031(d) and Tex. Gov’t Code Ann. ch. 2003.
  2. The parties received proper and timely notice of the hearing. Tex. Gov’t Code Ann §§2001.051 and 2001.052; 1 Tex. Admin. Code §155.27.
  3. The Carrier should reimburse the Provider $1,080 for each of the three days of treatment that it has not already reimbursed the Provider.

ORDER

THEREFORE, Transcontinental Insurance Company is ordered to pay Petitioner $3,240.00 for treatment provided January 9, 10, and 11, 2001.

Signed November 25, 2002.

SARAH G. RAMOS
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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