Texas Workers' Compensation

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§ 134.501. Initial Pharmaceutical Coverage

(a) For injuries which occur on or after December 1, 2002, the insurance carrier (carrier) shall pay for specified pharmaceutical services sufficient for the first seven days following the date of injury, regardless of issues of liability for or compensability of the injury that the carrier may have, if, prior to providing the pharmaceutical services, the health care provider (HCP) obtains both a verification of insurance coverage, and an oral or written confirmation that an injury has been reported. For purposes of this rule, specified pharmaceutical services are prescription drugs and over-the-counter medications prescribed by a doctor that cure or relieve the effects naturally resulting from the compensable injury, promote recovery, or enhance the ability of the employee to return to or retain employment.

(1) In determining the first seven days following the injury, the date of the injury is not counted. The first day after the date of injury shall be counted as “day one.” The last day of the seven-day period shall be known as “day seven.”

(2) If the pharmaceutical services are provided after day one, the carrier’s reimbursement under this section is limited to the date the pharmaceutical services were actually provided through day seven. (Example: The pharmaceutical services were provided on day four. The carrier’s liability for payment under this section would be for pharmaceutical services in an amount prescribed that would be the quantity sufficient for days four, five, six and seven.)

(3) Payment for the specified pharmaceutical services for the first seven days following the date of injury shall be in accordance with § 134.503 of this title (relating to Reimbursement Methodology). The dispensing fee for the initial prescription shall not be denied, prorated, or reduced even if the HCP provided pharmaceutical services beyond the first seven days following the date of injury and the carrier disputes or denies the pharmaceutical services beyond the first seven days following the date of injury.

(b) The carrier may be eligible for reimbursement from the subsequent injury fund (SIF) for payments made under subsection (a) as provided in Chapter 116 of this title.

(c) The HCP can verify insurance coverage and confirm the existence of a report of an injury by calling the employer or the carrier. Upon request, the employer and/or the carrier shall verify coverage and confirm any report of an injury. For verifying insurance coverage, the HCP can also review the commission’s internet-based coverage verification system.

(1) The HCP shall document verifications and confirmations not obtained in writing by indicating how the verification or confirmation was obtained (date obtained, from whom, etc.).

(2) The HCP shall affirm on the bill for the pharmaceutical services, in the form and manner prescribed by the commission, that the HCP verified that there is insurance coverage and confirmed that an injury has been reported.

(d) Notwithstanding any other provision of this section, the HCP may dispense prescription or nonprescription medications in the amount ordered by the prescribing doctor in accordance with applicable state and federal law (not to exceed the limits imposed by § 134.502 of this title (relating to Pharmaceutical Services)).

(e) The HCP and carrier may voluntarily discuss approval of pharmaceutical services beyond the seven days following the date of injury as provided in Texas Labor Code § 413.014(e) and § 134.600 of this title (relating to Preauthorization, Concurrent Review, and Voluntary Certification of Health Care).

(f) Communication is important to ensure prompt delivery of pharmaceutical services.

(1) Injured employees (employees) are encouraged to immediately report their injury to their employer.

(2) Employees are encouraged to ask for, and employers to provide, a written statement that confirms an injury was reported to the employer and identifies the date of injury (as reported by the employee) and the employer’s insurance carrier. Verifying that there is insurance coverage and/or confirming that an injury was reported does not waive the employer’s right to contest compensability under Texas Labor Code § 409.011 should the carrier accept liability for the payment of benefits.

(3) The carrier’s verification of coverage and/or confirmation of a reported injury does not waive the insurance carrier’s right to further review the claim under Texas Labor Code § 409.021 and § 124.3 of this title (relating to Investigation of an Injury and Notice of Denial/Dispute).

The provisions of this § 134.501 adopted to be effective November 7, 2002, 27 TexReg 10391.

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At a Glance:

Title:

§ 134.501. Initial Pharmaceutical Coverage

Title:

Title 28. Insurance

Status:

Current

Usage:

New Law Rule

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