GQ Corner
Q. The claimant was working on a job in Oregon when he sustained an injury. He was hired in Oklahoma several years back but has resided in Texas since and continues to do so. Most of his work is done here in Texas (and indeed he worked here for at least 10 days over the year preceding the claim injury) but he does travel out of state approximately 30% of the time. Would this be a compensable claim for which benefits are payable in Texas?
A. Yes, assuming the evidence establishes a compensable injury under Texas law. Texas Labor Code Section 406.071 addresses extraterritorial coverage with respect to injuries occurring outside of Texas. Specifically, that section provides that an employee injured while working in another jurisdiction (outside of Texas) is entitled to all rights and remedies under our Texas scheme if (1) the injury would be compensable if it had occurred in this state and (2) the employee has significant contacts with this state or the employment is principally located in this state. The statute elaborates that an employee has “significant contacts” with Texas if he or she was hired or recruited in Texas and was injured not later than one year after the date of hire; or (2) has worked in this state for at least 10 working days during the 12 months preceding the date of injury. Under your facts, it appears the “significant contacts” test is satisfied.
Q. Does Texas require adjusters to submit requests for medication to utilization review (UR) every month? Can an Old Law claimant be “grandfathered in” such that medication requests do not have to go through UR?
A. All medical care in Texas is subject to utilization review. In Texas, this process is largely divided into two categories: prospective review and retrospective review. In 2011, Texas adopted a closed formulary for workers’ compensation prescription drugs. Drugs that are on the formulary are subject to retrospective review by a URA after you have received a bill from the provider. Drugs that are off of the formulary are subject to prospective review (preauthorization) by a URA, which will determine whether the prescription is medically necessary. The closed formulary applies to the provision of any drug prescribed for a workers’ compensation claimant and the rules do not provide for any “grandfathering” of a claim (at least for injuries occurring on or after January 1, 1991). A great deal of information about the formulary (including links to DWC Rules and memos) can be found at this page on the DWC website.
The claimant in your case may be referring to a treatment plan. Parties can engage in treatment planning whereby an employee (usually through the prescribing doctor) and the carrier (through its URA) agree to the provision of certain prescription medication in a manner that may modify the obligation to obtain preauthorization or to go through retrospective review. Such a treatment plan, if one were created in your claim, would have been written and copies would have been sent to all parties. Generally, treatment plans are applicable for a defined term (6 months, one year, etc.). A treatment plan, if such exists, would have been negotiated for you by a URA and reduced to writing. Given the date of injury in this claim, it would probably have been negotiated between September 1, 2011 and September 1, 2013. Under these circumstances, it may be wise to review your claim notes for that period carefully and to double check with the URA you were using at that time to see if they have documentation of a treatment plan. If you cannot find a treatment plan that applies, any bills for on-formulary drugs should go through retrospective review; any bills for off-formulary drugs should go through prospective review (in accordance with Rule 134.600).
FOLIO
