28 Tex. Admin. Code § 134.501 - Initial Pharmaceutical Coverage
(a)
For injuries that occur on or after December 1, 2002, the insurance carrier
must 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 insurance carrier may have, if, before
providing the pharmaceutical services, the health care provider obtains both a
verification of insurance coverage and an oral or written confirmation that an
injury has been reported.
(1) 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 injured employee to return to or retain
employment.
(2) 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 is "day one." The last day of the
seven-day period is "day seven."
(3) If the pharmaceutical services are
provided after day one, the insurance 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 insurance 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.)
(4) Payment for the specified pharmaceutical
services for the first seven days following the date of injury must comply with
§
134.503 of this title (Pharmacy
Fee Guideline). The insurance carrier must not deny, prorate, or reduce the
dispensing fee for the initial prescription even if the health care provider
provided pharmaceutical services beyond the first seven days following the date
of injury, and the insurance carrier disputes or denies the pharmaceutical
services beyond the first seven days following the date of injury.
(b) The insurance 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 health care provider can verify
insurance coverage and confirm the existence of a report of an injury by
calling the employer or the insurance carrier. On request, the employer or the
insurance carrier must verify coverage and confirm any report of an injury. For
verifying insurance coverage, the health care provider can also review the
division's internet-based coverage verification system.
(1) The health care provider must document
verifications and confirmations not obtained in writing by indicating how the
verification or confirmation was obtained (date obtained, from whom,
etc.).
(2) The health care provider
must affirm on the bill for the pharmaceutical services, in the form and manner
prescribed by the division, that the health care provider verified that there
is insurance coverage and confirmed that an injury has been reported.
(d) Notwithstanding any other
provision of this section, the health care provider may dispense prescription
or nonprescription medications in the amount ordered by the prescribing doctor
under applicable state and federal law (not to exceed the limits imposed by §
134.502 of this title
(Pharmaceutical Services)).
(e) The
health care provider and insurance 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
(Preauthorization, Concurrent Utilization Review, and Voluntary Certification
of Health Care).
(f) Communication
is important to ensure prompt delivery of pharmaceutical services.
(1) Injured employees are encouraged to
immediately report their injury to their employer.
(2) Injured 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
injured employee) and the employer's insurance carrier. Verifying that there is
insurance coverage 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
insurance carrier accept liability for the payment of benefits.
(3) The insurance carrier's verification of
coverage 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 (Investigation
of an Injury and Notice of Denial or Dispute).
Notes
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