DWC064 Texas Department of Insurance Division of Workers' Compensation 7551 Metro Center Drive, Suite100 · MS-41 Austin, TX 78744-1645 (512) 804-4000 phone · (512) 804-4874 fax Fax Completed Form To: (512) 804-4874 Medical Interlocutory Order Request Continued Use of a Drug Previously Prescribed and Dispensed and Excluded from TDI-DWC's Closed Formulary Type (or print in black ink) each item on this form All Medical Interlocutory Order (MIO) claims requests must be made in accordance with the Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC), 28 Texas Administrative Code (TAC) §134.550, which lists the MIO requirements for TDI-DWC approval. Requester: Prescribing Doctor Pharmacy Date of Request: Time of Request: I. Prescribing Doctor Contact Information (for TDI-DWC response to MIO request) 1. Prescribing Doctor Name (First, Last) 3. Prescribing Doctor Telephone Number 2. Prescribing Doctor NPI 4. Prescribing Doctor Fax Number or E-mail II. Pharmacy Contact Information (for TDI-DWC response to MIO request) 5. Pharmacy Name 7. Pharmacy NPI 6. Pharmacist Name (First, Last) 8. Pharmacy/Pharmacist Telephone Number 9. Pharmacy/Pharmacist Fax or E-mail III. Injured Employee/Claim Information 10. Injured Employee Name (First, Last) 14. Insurance Carrier Name 11. Injured Employee DOB 12. Injured Employee SSN (last four digits) xxx-xx15. Insurance Carrier Claim Number 13. Injured Employee Date of Injury 16. TDI-DWC Claim Number IV. Requested Prescription Drug Information (must be identical to prescription denied preauthorization) 17. Prescription Drug Name 18. Prescription Drug Dosage 19. Prescription Drug Duration V. Requester Certification and Signature 20. I hereby certify the following under penalty of law: · · · · · The preauthorization request for the previously prescribed and dispensed drug identified in Section IV has been denied by the insurance carrier or its utilization review agent (URA). An independent review request has been submitted to the insurance carrier or its URA in accordance with 28 TAC §133.308. The denial poses an unreasonable risk of a medical emergency as defined in 28 TAC §134.500 (7). The potential medical emergency has been documented in the preauthorization process. The insurance carrier has been notified that a request for an MIO is being submitted to TDI-DWC. Requester Printed Name: ________________________________________________________ Requester Signature: ___________________________________________________________ Date of Signature:_________________ Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC) Response Approved as requested Denied (Reason for denial) MIO Effective Date: Signature: Date of Signature: Drugs dispensed as a result of an approved MIO are payable by the insurance carrier in accordance with TDI-DWC rules. NOTE: With few exceptions, upon your request, you are entitled to be informed about information TDI-DWC collects about you; receive and review the information (Government Code, §§552.021 and 552.023); and have TDI-DWC correct information that is incorrect (Government Code, §559.004). DWC064 Rev. 08/11 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com DWC064 Frequently Asked Questions Medical Interlocutory Order Request Continued Use of a Drug Previously Prescribed and Dispensed and Excluded from TDI-DWC's Closed Formulary (DWC-Form 064) Who submits the MIO Request Form? A prescribing doctor or pharmacy may submit the MIO Request form if a preauthorization denial of a previously prescribed and dispensed drug that is excluded from the TDI-DWC closed formulary poses an unreasonable risk of a medical emergency as defined in 28 TAC §134.500(7) and Texas Insurance Code §1305.004(a)(13). The following chart provides detailed instructions regarding information the requester (Prescribing Doctor or Pharmacist) must provide. Failure to provide all required information may result in denial of the MIO Request. Prescribing Doctor Section I. Prescribing Doctor Information Section II. Pharmacy Information Section III. Injured Employee/Claim Information Section IV. Prescription Drug Information Section V. Requester Certification and Signature Required Provide if known Boxes 10 and 11, Required Boxes 12-16, Provide if known Required Required Pharmacist Box 1, Required Boxes 2-4, Provide if known Required Boxes 10 and 11, Required Boxes 12-16, Provide if known Required Required Am I required to use the DWC Form-064 to submit an MIO request? Written requests that contain all elements required by 28 TAC §134.550(c) will be accepted by TDI-DWC. What is the time-frame for submitting an MIO request? · Initial preauthorization denial -- within 15 days · Reconsideration denial -- within 5 working days What are the effective dates of an approved MIO? Upon approval, an MIO is effective retroactively to the date the complete request was received by TDI-DWC. The MIO continues in effect until the later of: · final adjudication of a medical dispute regarding the medical necessity and reasonableness of the drug contained in the MIO; · expiration of the period for a timely appeal; or · agreement of the parties. Where do I send the MIO request? To submit the MIO request to TDI-DWC, fax to 512-804-4874. You must also provide a copy of the request to the insurance carrier, prescribing doctor, injured employee, and dispensing pharmacy (if known), on the date you submit the MIO Request to TDI-DWC. Where can I find the regulatory requirements for the DWC Form-064? The regulatory requirements for the DWC Form-064 are outlined in 28 of TAC, §134.550. The complete text of these rules is available on TDI-DWC's website at www.tdi.texas.gov/wc/rules/index.html. Questions? Contact TDI-DWC for help in completing this form or with questions about Medical Interlocutory Orders, call CompConnection for Healthcare Providers, at 1-800-372-7713 or 804-4000 in the Austin area and select extension 3. IMPORTANT NOTE: Requesters are reminded that in the case of a life-threatening emergency, injured employees should be advised to go to the emergency room. DWC064 Rev. 08/11 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com