Seminars on Texas Pharmacy Formulary and Claims/eBill

pic6The Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) will present a series of free, half-day educational seminars titled Pharmacy Closed Formulary and Clean Claims/eBill. The seminars are being offered in cooperation with Small Business Development Centers.



The Pharmacy Closed Formulary portion of the seminar will provide an overview of the pharmacy closed formulary rules adopted by the TDI-DWC in December 2010 for both certified network and non-network workers’ compensation claims with dates of injury on or after Sept. 1, 2011.



The Clean Claims/eBill portion of the seminar will provide an overview of the new TDI-DWC requirements related to submitting paper and electronic medical bills, including a discussion of the changes from the previous requirements and a brief introduction to the new electronic medical billing standards. This presentation also provides an opportunity for new and experienced medical billing employees to recognize how to complete medical bills to minimize insurance carrier returns or rejections after the Aug. 1, 2011 effective date.(WCxKit)


House bill 528, which becomes effective June 17, can be found here.


Among some the regulations in the bill include:

  1. Insurance carriers must reimburse health care providers in accordance with the TDI-DWC’s pharmacy fee guideline or at a contracted rate.
  2. Insurance carriers may also reimburse health care providers for pharmaceutical services at rates inconsistent with the TDI-DWC’s pharmacy fee guideline if the carrier has a contract with that health care provider that includes a specific fee schedule.
  3. Insurance carriers or their authorized agents may use a pharmacy informal or voluntary network to obtain these contractual agreements with health care providers. If an insurance carrier chooses to use a pharmacy informal or voluntary network, there must be: a contractual arrangement between the insurance carrier or its agent and the pharmacy informal or voluntary network authorizing the network to contract with health care providers for pharmaceuticals on the insurance carrier’s behalf; and a contract between the network and the health care providers that includes a specific fee schedule and complies with the health care provider notice requirements of Texas Labor code.
  4. The carrier must notify each health care provider, at least quarterly of any person, other than the injured employee, to which the network’s contractual fee arrangements with the health care providers are sold, leased, transferred or conveyed.
  5. Each informal or voluntary network that has contracts in effect on June 17, 2011, must report the information listed in the labor code by July 17, 2011.
  6. Failure for a pharmacy informal or voluntary network to comply with the registration requirements will result in an administrative violation.


Details of these new requirements will be explained at the conference.


Due to limited space, registration is required. For more details on the following educational seminars, visit the TDI-DWC Events and Training Calendar at Pharmacy Closed Formulary will be presented from 8 a.m. to 11 a.m. and Clean Claims/eBill will be presented from 11 a.m. to 12 p.m. at each venue. Texas workers’ compensation system participants may attend one or both portions of the seminar.



Training Dates

Date                       City

May 6, 2011          Dallas

May 7, 2011          Fort Worth

May 20, 2011        San Antonio

May 25, 2011        Wichita Falls

June 3, 2011        Corpus Christi

June 8, 2011        San Antonio

June 10, 2011      Houston

June 24, 2011      Edinburg

July 15, 2011        El Paso

Aug. 18, 2011       Austin



This information was provided by attorney Stuart Colburn, a Shareholder at Downs Stanford in Austin, Texas. Colburn has extensive experience in all phases of dispute resolution before the Texas Department of Insurance, Division of Workers Compensation and in district courts across the state. Stuart represents clients regarding workers compensation, non-subscription, subrogation, and bad faith litigation. He is the founder and the first chairman of the State Bar of Texas (SBOT) Workers Compensation Section; course coordinator for the SBOT the Advanced Workers Compensation Seminar; and course coordinator for the Texas Workers Compensation Forum. He can be reached at:


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