GQ Corner

Q. The claimant lives in Oklahoma, but travels more than 100 miles into Texas to get his prescriptions filled. The doctor is not submitting for pre-authorization the medications as required. The claimant has also submitted various requests for reimbursement of mileage and other expenses supposedly incurred while traveling between his home and the doctor’s office to pick up the medications. Is the carrier liable for the medications and requested reimbursement? 

A. No. If the provider is not submitting the pre-authorization requests as required and the claimant is not submitting a request for reimbursement regarding the actual medications, you have a defense to liability for the medications and a defense to payment of the requested travel reimbursement. Furthermore, you are only liable for travel reimbursement if medical treatment for the compensable injury is not reasonably available within 30 miles from the claimant’s residence and the distance traveled to secure that treatment is greater than 30 miles one-way, so you may assert a defense if medical treatment for the compensable injury is reasonably available within 30 miles from the claimant’s residence. 

Q. If an employee is off work due to surgery for the compensable injury, then leaves the country to visit  family for two months during which time he will not be receiving treatment, can TIBs be stopped during that time? 

A. No. If the employee does not otherwise have the ability to obtain employment at the preinjury wage, then the employee remains disabled and, thus, entitled to TIBs.