Texas Workers' Compensation Preauthorization: Provider Request and Appeal Guide

Preauthorization is a prospective medical-necessity control. It is not the same as a retrospective medical-fee dispute. A provider that treats first and later receives a payment reduction cannot repair a missing preauthorization through the medical-fee dispute process. Conversely, an authorization does not resolve every compensability, extent-of-injury, coding, or payment issue.

This guide addresses Texas non-network workers' compensation requirements reflected in Texas Department of Insurance, Division of Workers' Compensation materials available on September 27, 2026. Certified workers' compensation networks operate under additional network rules and contracts; providers should verify whether the claim is in a network before applying the non-network workflow below.

Texas preauthorization workflow at a glance

1. Determine whether the claim is network or non-network

The Division's provider guidance separates non-network preauthorization under Labor Code § 413.014 and 28 TAC § 134.600 from certified-network utilization review under Insurance Code Chapters 4201 and 1305, Chapter 10 rules, and the provider's network contract. The service list, submission route, and appeal language can differ. Intake staff should capture network status, the utilization-review agent, the carrier's designated contact information, and the controlling plan or contract before requesting care.

2. Identify care that requires preauthorization

For non-emergency, non-network care, § 134.600(p) lists categories that require approval before treatment. The list is specific enough to use as a screening tool but still requires code-level and fact-specific review.

Emergency care is treated differently. Section 134.600 ties carrier liability for listed care to an emergency, a timely preauthorization or concurrent-review approval, or another rule-based basis. Document the clinical facts supporting any emergency exception rather than applying the label after the fact.

3. Submit a complete request

The request may be sent by telephone, fax, or electronic transmission to the carrier's designated access point. Under § 134.600(f), the submission should contain all information needed to define the requested course of care and route the decision correctly.

• Injured employee's name and claim-identifying information used by the carrier.
• The specific health care being requested.
• The number of treatments and the period requested to complete them.
• Clinical information substantiating medical necessity.
• Accessible provider telephone and fax numbers and, if used, an electronic address.
• Requestor's name and professional license number or National Provider Identifier.
• Rendering provider's name and identifier when different from the requestor and known.
• Facility name and NPI when care will be rendered at a facility.
• Estimated date of the proposed health care.

Make the clinical rationale reviewable

A complete form is not necessarily a persuasive record. Tie the requested service to the accepted injury, current objective findings, functional deficits, prior care, response or failure, guideline recommendation, and expected measurable benefit. When the request departs from a treatment guideline, explain the clinical reason for the departure and attach the records on which the clinician relies.

1. State the diagnosis and body part as the carrier currently recognizes them.
2. Describe the present impairment and objective examination or test findings.
3. Identify prior conservative care, duration, adherence, and documented response.
4. Cite the guideline or protocol supporting the request, or explain why the patient's facts warrant different care.
5. Specify CPT, HCPCS, drug, equipment, units, frequency, duration, and site of service when applicable.
6. State the anticipated functional outcome and how it will be measured.
7. Index attachments and preserve the exact packet sent.

4. Track the carrier's decision period

The carrier must communicate its preauthorization decision within three working days after receipt. The decision may approve the request, issue an adverse determination, or—when the request concerns a condition the carrier does not accept—deny on relatedness grounds under the applicable rule. Written notice follows within one working day after the decision to the injured employee, representative, and requestor as specified by § 134.600(j).

The rule states that an issued preauthorization approval may not be withdrawn. The approval should identify the specific care, approved number of treatments and time period, unresolved compensability or relatedness disputes, and the carrier's approval number. Provider teams should compare that document with the request before scheduling and resolve any mutually agreed change in writing.

5. Use reconsideration after a medical-necessity denial

If the initial response is an adverse determination, the requestor or injured employee may seek reconsideration orally or in writing. The request must be made within 30 days after receipt of the written adverse determination and should be documented. For preauthorization, the carrier must respond as soon as practicable but no later than the 30th day after receiving reconsideration; the applicable procedure must also account for the clinical immediacy of the condition.

• Quote the exact adverse rationale and reviewer criteria.
• Correct material factual errors about diagnosis, prior care, or requested scope.
• Add new objective findings or missing records rather than resending an undifferentiated chart.
• Explain the guideline fit or the clinical basis for an exception.
• Request the available peer discussion when a clinical issue can be clarified.
• Preserve the reconsideration submission, delivery proof, discussion notes, and written response.

A request for the same care should not simply be refiled. Section 134.600 permits resubmission when objective clinical documentation supports a substantial change in the employee's condition or shows that previously unmet clinical prerequisites are now satisfied. Frivolous resubmission may be treated as an administrative violation.

6. Route the remaining dispute correctly

A denied reconsideration of an adverse medical-necessity determination may proceed through the medical-dispute process under Labor Code § 413.031 and related Division rules. But a denial based on an injury or diagnosis being outside the accepted compensable injury raises an extent-of-injury issue. Section 134.600 states that this relatedness denial does not proceed as a medical dispute on that ground; the employee may need the benefit-review process.

7. Preserve authorization through billing

The authorization record should travel with scheduling, treatment, coding, and billing. Retain the request, delivery receipt, approval number, authorized codes or service description, unit limit, date range, facility, rendering provider, and any unresolved dispute language. Before treatment, compare the scheduled service with the authorization. Before billing, compare the claim line with both the operative report or clinical note and the approved scope.

Provider quality-control checklist

• Network status and carrier utilization-review contact confirmed.
• Proposed care screened against § 134.600(p) and any pharmaceutical rule.
• Emergency or first-six-visit exception documented only when its facts are satisfied.
• Service, units, duration, facility, rendering provider, and proposed date are specific.
• Clinical rationale addresses accepted injury, objective findings, prior care, guideline fit, and expected outcome.
• Transmission receipt and complete submitted packet preserved.
• Three-working-day decision period calendared from confirmed receipt.
• Written approval or adverse determination reconciled with the request.
• Thirty-day reconsideration deadline calendared after an adverse determination.
• Medical necessity, relatedness, compensability, and fee disputes routed separately.
• Final authorization number, scope, and date range carried into billing.

Related Millennova Legal resources

See Millennova Legal's workers' compensation dispute support and Texas workers' compensation guide for broader context. When the issue is payment after services rather than prospective authorization, use the Texas medical-fee dispute resolution guide. For a comparison with another state's treatment-review system, see the California utilization review and IMR guide.

Texas primary sources