1. Check network rules: California Medical Provider Network participation, Texas certified network status, and New York Board authorization for the treating provider.

2. Before scheduling surgery, advanced imaging, injections, DME or extended therapy, check whether the state requires authorization and start the request early.

3. Rette’s agents read the operative and clinical notes in the EHR your practice already uses and check documentation against NCD and LCD criteria before a request or claim goes out. Prior authorization, denials, appeals and workers’ compensation work sit in one prioritized queue, so WISeR requests, ADR deadlines and resubmissions are tracked alongside your other payer work.

Rette’s agents read the operative and clinical notes in the EHR your practice already uses, suggest codes, and validate claims against NCCI, NCD and LCD rules before submission. Prior authorization, denials, appeals and workers’ compensation work sit in one prioritized queue, so staff can see what needs attention first.

Orthopedic practices treat a steady stream of work injuries: fractures, rotator cuff and meniscus tears, back injuries, and the surgery and therapy that follow. Those claims don’t run on health plan rules. A state agency sets the fee schedule, decides what needs approval first, and requires its own reports, forms and deadlines.

This guide explains how workers’ comp billing differs from health insurance, compares three large systems (California, New York and Texas) using each state’s own rules, and walks through common orthopedic denials and intake steps. Rules and forms change often, so confirm edge cases with the state agency, the claims administrator or your compliance team.

How is workers’ comp different from billing a health plan?

• State law sets the rules. Each state’s statute and agency regulations govern coverage, payment and disputes. Medicare policies apply only where a state adopts them, as Texas does for coding and payment policy on non-network professional claims.

• The claim number comes from the employer’s carrier. The insurer, self-insured employer or third-party administrator assigns a claim number to each injury. New York also issues a Workers’ Compensation Board (WCB) case number, which belongs in field 9a of the CMS-1500 when known.

• The worker has no cost-sharing to collect. California, New York and Texas all restrict providers from collecting from the injured worker (see the FAQ below).

• Prices come from a state fee schedule, unless the state allows a network or contract rate.

• Treatment guidelines drive approvals. California uses the Medical Treatment Utilization Schedule (MTUS), New York its Medical Treatment Guidelines (MTGs), and Texas the Official Disability Guidelines (ODG) for non-network claims. Utilization review applies those guidelines to treatment requests.

• Reports are part of the claim. Each state requires initial, progress and work-status reporting, and missing reports stall payment.

• MMI, impairment ratings and independent exams shape the case. Physicians decide when the worker has reached maximum medical improvement (MMI) and rate any permanent impairment.

• Disputes go through state processes such as bill review, arbitration, independent review or liens, not a health plan’s appeal levels.

How do California, New York and Texas compare?

California

Treatment requests go on the DWC Form RFA with documentation supporting medical necessity. Under the utilization review (UR) regulation, prospective decisions are due within 5 business days of a complete RFA, or 72 hours for expedited review. Outside expedited and concurrent review, a fax sent after 5:30 p.m. Pacific counts as received the next business day. The requesting physician must be told of the decision within 24 hours, with written notice within 2 business days for prospective review. If the reviewer asks for missing records and doesn’t get them within 14 days, the request is denied until they arrive.

The MTUS is presumed correct on the extent and scope of treatment. A physician who wants care that varies from it must rebut that presumption with a preponderance of scientific medical evidence, and conditions the MTUS doesn’t address follow other evidence-based guidelines. File the Doctor’s First Report of Occupational Injury or Illness within 5 working days of the first exam, then PR-2 reports when the condition or plan changes and at least every 45 days during ongoing treatment. Bills must include the itemization, copies of reports and any authorization, and must be submitted within 12 months of service for dates on or after January 1, 2017.

New York

New York replaced the C-4 family of physician reports (C-4, C-4.2, C-4AMR and related forms) with the CMS-1500 on July 1, 2022. The initial bill and narrative are due within 48 hours of first treatment, a follow-up 15 days after first treatment, and later reports after follow-up visits no more than 90 days apart. Every narrative must state work status, causal relationship and temporary impairment percentage. Since August 1, 2025, bills must go through a Board-approved electronic submission partner. Form C-4.3 remains in use as the narrative attached to MMI and permanency bills.

Treatment consistent with the MTGs doesn’t need prior approval, except listed special services such as knee arthroplasty, osteochondral autograft, autologous chondrocyte implantation, meniscal allograft, lumbar fusion and bone growth stimulators. MTG variances, special services, and non-MTG treatment over $1,000 require a PAR, submitted in OnBoard through the Board’s Medical Portal; these replaced the paper MG-2 and C-4AUTH forms. Providers generally must be Board-authorized before treating injured workers.

Texas

Texas doesn’t require most private employers to carry workers’ comp, so confirm coverage before treating. For non-network care, DWC applies Medicare’s RVUs, coding and payment policies, including correct coding (NCCI procedure-to-procedure) edits and modifiers, with Texas conversion factors. DWC’s quick estimate puts its 2026 factors at about 216% of the Medicare rate for most services and 271% for surgery in a facility. Certified network claims follow the network contract.

Non-network preauthorization covers listed services, including outpatient or ambulatory surgery, inpatient admissions, spinal surgery, DME over $500 per item, physical and occupational therapy (except the first six visits within two weeks of the injury or a preauthorized surgery), and treatment the ODG doesn’t recommend or address. Office visits don’t need it. After the first exam, and after any change in work status or substantial change in restrictions, the treating doctor gives the worker a DWC-073 at the visit and sends it to the carrier and employer within 2 working days. Bills go on the CMS-1500 within 95 days.

What happens at MMI, impairment rating and independent exams?

MMI is the point where the condition has stabilized. California’s “permanent and stationary” status means the same thing: well stabilized and unlikely to change substantially in the next year. Each state then has a rating and examination process:

• California: the primary treating physician reports permanent and stationary findings within 20 days of the exam, describing impairment under the AMA Guides, 5th Edition (Form PR-4). Qualified and agreed medical evaluators handle medical-legal evaluations.

• New York: the treating physician bills the MMI or permanency exam on the CMS-1500 with Form C-4.3 attached. Independent medical exam reports go on the IME-4 cover sheet, with copies due the same day to the Board, carrier, attending physician and worker.

• Texas: designated doctors, requested through DWC, address questions such as MMI and impairment using the AMA Guides, 4th Edition, and report on the DWC-069 Report of Medical Evaluation. Reaching MMI doesn’t end treatment approvals; preauthorization decisions must still rest on medical necessity.

How are payment disputes and liens resolved?

California separates amount disputes from everything else. Request a second bill review within 90 days of the explanation of review; the claims administrator has 14 days to respond. If the amount is still disputed, file Independent Bill Review within 30 calendar days. Medical necessity disputes go to Independent Medical Review. Other disputes, such as denied liability, go to the Workers’ Compensation Appeals Board, where providers file liens electronically with a $150 fee. For services on or after July 1, 2013, a lien must be filed within 18 months of the service date.

New York requires payers to pay or object on Form C-8.1B within 45 days. If a bill stays unpaid without an open legal objection, file Form HP-1.0 in OnBoard for arbitration; paper HP-1.0 forms are no longer accepted.

Texas sends amount disputes to medical fee dispute resolution on DWC Form-060, filed within one year of service, with limited exceptions. Medical necessity denials go to reconsideration and then an independent review organization (Form LHL009, within 45 days of the reconsideration denial).

What are the common workers’ comp denials in orthopedics, and how do you prevent them?

Most of these trace back to intake and documentation rather than coding. The reason codes below are examples; payers choose their own. For denial patterns outside workers’ comp, see our guide to common orthopedic claim denials.

Authorization records matter even after the fact. In a June 2026 Texas fee dispute over physical therapy, the carrier’s reductions included CARC 197, and DWC ordered no additional payment because the provider didn’t submit an authorization showing the approved dates and units.

What intake steps should your front desk follow?

1. Ask every injury patient whether the injury happened at work, and flag the account before anything is billed to a health plan.

2. Record the employer’s name and address, the date of injury, and the body parts and mechanism of injury in the patient’s words.

3. Identify the carrier or third-party administrator and the claim number; in New York, also capture the WCB case number when one exists.

4. In Texas, confirm the employer has coverage, since coverage is optional for most private employers.

5. Confirm with the adjuster that the claim is open and which body parts are accepted; note the adjuster’s name, phone number and the date.

6. Check network rules: California Medical Provider Network participation, Texas certified network status, and New York Board authorization for the treating provider.

7. Don’t collect copays or deductibles; explain that the carrier pays.

8. Before scheduling surgery, advanced imaging, injections, DME or extended therapy, check whether the state requires authorization and start the request early.

9. Calendar report and billing deadlines: California’s Doctor’s First Report within 5 working days, New York’s initial narrative within 48 hours, and Texas’s DWC-073 to the carrier within 2 working days.

How Rette helps

Rette’s agents read the operative and clinical notes in the EHR your practice already uses, suggest codes, and validate claims against NCCI, NCD and LCD rules before submission. Prior authorization, denials, appeals and workers’ compensation work sit in one prioritized queue, so staff can see what needs attention first.