Texas Register

TITLE 28 INSURANCE
PART 2TEXAS WORKERS' COMPENSATION COMMISSION
CHAPTER 134BENEFITS--GUIDELINES FOR MEDICAL SERVICES, CHARGES AND PAYMENTS
SUBCHAPTER FPHARMACEUTICAL BENEFITS
RULE §134.504Pharmaceutical Expenses Incurred by the Injured Employee
ISSUE 08/31/2001
ACTION Proposed
Preamble Texas Admin Code Rule

(a)It may become necessary for an injured employee to purchase prescription drugs or over-the-counter alternatives to prescription drugs prescribed or ordered by the treating doctor or referral health care provider. In such instances the injured employee may request reimbursement from the insurance carrier by submitting a request to the carrier.

(b)The injured employee shall submit to the insurance carrier a letter requesting reimbursement along with a receipt indicating amount paid and a copy of the prescription. The letter should include information to clearly identify the claimant such as the claimant's name, address, date of injury, and social security number.

(c)The insurance carrier shall make appropriate payment to the injured employee in accordance with commission Rule 134.503, or notify the injured employee of a reduction or denial of the payment within 45 days of receipt of the request for reimbursement from the injured employee. If the insurance carrier does not reimburse the full amount requested, partial payment or denial of payment shall include a full and complete explanation of the reason(s) the insurance carrier reduced or denied the payment and shall inform the injured employee of his or her right to request medical dispute resolution in accordance with §133.305 of this title (relating to Medical Dispute Resolution). The statement shall include sufficient claim-specific substantive information to enable the employee to understand the insurance carrier's position and/or action on the claim. A general statement that simply states the carrier's position with a phrase such as "not entitled to reimbursement" or a similar phrase with no further description of the factual basis does not satisfy the requirements of this section.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State, on August 20, 2001

TRD-200104908

Susan Cory

General Counsel

Texas Workers' Compensation Commission

Earliest possible date of adoption: September 30, 2001

For further information, please call: (512) 804-4287



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