SCHOOL POOL FOR EXCESS LIABILITY LIMITS

Transcription

1 SCHOOL POOL FOR ECESS LIABILITY LIMITS JOINT INSURANCE FUND ACCASBOJIF, BCIPJIF, & GCSSDJIF CLAIM COORDINATOR MANUAL S P E L ACCASBO L BCIP GCSSD SEJIF I F REVISED OCTOBER 2013

2 Section 2 WORKERS COMPENSATION CLAIMS

3 Workers Compensation Claims (Employee injuries sustained on the job) Types of Claims/Objectives/Reporting Instructions I. Types of Losses to be Reported: Any injury sustained by an employee of a member district during the course of his/her employment regardless of whether medical treatment is required (traumatic injuries). Any injury allegedly sustained by an employee of a member district arising from an exposure suffered during the course of his/her employment over a period of time (occupational disease injuries). II. Objectives: 1) To record all incidents even if they are not claims. A claim is when an injured employee wants to see a doctor. 2) To promptly refer an injured employee for medical attention. 3) To quickly report the claim to QualCare to ascertain compensability. WHAT TO DO WHEN AN EMPLOYEE GETS HURT ON THE JOB 1. Show genuine concern for the injured employee's welfare. 2. Direct injured employee to the School Nurse for triage. 3. Claim Coordinator to work with injured employee in completing the Employee Report. 4. If needed, direct injured employee to your authorized District physician. You can use the "Employee Authorization for Medical Attention Form" (sample attached), at your district s option. Do not use the emergency room unless emergency treatment is required. Emergency Room vs. Urgent Care Centers See page Call QualCare using the toll free telephone number and report the claim immediately QualCare will: A. Take all of the information necessary to complete the First Accident Report (FAR). See forms section. SPELLJIF Claim Coordinator s Handbook Revised 10/13

4 B. Immediately assign a Medical Care Coordinator or a Nurse Case Manager to follow up with the employee and physician to manage medical treatment and return to work status. C. QualCare will immediately notify Qual-Lynx of the claim. D. QualCare will fax a copy of the First Accident Report Confirmation (FARC) and a First Report of Injury or F.R.O.I. (samples attached), to the District Claim Coordinator (DCC). The DCC needs to verify all information on both reports and provide all corrections to QualCare. QualCare will transmit this information to Qual-Lynx and Qual-Lynx will first review the information for completeness and once satisfied will electronically file the F.R.O.I. with the State of New Jersey. 6. Once Qual-Lynx is notified about your claim by QualCare, an adjuster will be assigned within 48 hours of the receipt of the notification. Once assigned, the adjuster will assign a claim number then call the DCC to gather additional information and discuss the claim. Once a claim number has been assigned the Qual-Lynx system will generate an Acknowledgment Letter that will be mailed to the DCC. The Acknowledgment will contain the name of the adjuster assigned and the claim number which you will use when following up or when transmitting additional documents to Qual-Lynx. 7. The District Claim Coordinator will receive a Duty Determination Instructions (DDI) form (copy attached) after every doctor s office visit. 8. The District Claim Coordinator will keep in contact with the injured employee, the employee's supervisor, the managed care service and the claims adjuster. 9. The District Claim Coordinator will work with the injured employee s direct supervisor in completing the Supervisor Report (copy attached). Do not delay the reporting of Workers Compensation Claims! Claims should be reported within 24 hours of accident. Do not hold up the claim simply because all of the information is not available. Provide as much information as you have at the time and indicate that additional information will be sent later SPELLJIF Claim Coordinator s Handbook Revised 10/13

5 EMPLOYEE REPORT PLEASE FILL OUT THIS FORM IN DETAIL. ANSWERING ALL QUESTIONS ASSURES PROMPT HANDLING OF YOUR CLAIM. Name Age Phone No. Address Social Security No. List all dependents (Full names, ages, relationship and birth dates) Name of Employer Name of Supervisor How many hours a day do you work? How many days a week? What are your wages per hour? Per day? Per week? Describe fully your physical trouble or disability Date and hour trouble first started 19 a.m./p.m. Explain fully and exactly what happened to you, or how your physical trouble or disability first started. (You can help us give your case prompt and proper attention if you will answer this question completely. The following is an illustration of the way to answer this question: A piece of wood about two inches square was thrown a distance of six feet by a power saw, striking the outer surface of my right leg about five inches above the knee. ) (IF YOU NEED MORE SPACE, PLEASE USE REVERSE SIDE OF THIS FORM.) Who witnessed the start of your trouble? Give names, addresses and phone numbers. If your disability was caused by another person, please give his name and address Give date and hour on which you first started to lose time from work a.m./p.m. When were you able to return to work? Are you fully recovered now? If you are still having trouble, explain fully your present condition and what parts of your body are affected: Date on which you first saw doctor Give names and addresses of all doctors you have seen Are you still receiving treatment? Have you had this or any other injuries at any time in the past? If so, explain the nature of that trouble and approximate date it happened Give name and address of employer for whom you were working at time of your previous trouble Give name and address of doctor who saw you for previous trouble Dated Signed MEDICAL TREATMENT BY A BOARD OF EDUCATION APPROVED PANEL PHYSICIAN WAS OFFERED AND DECLINED BY THE EMPLOYEE, AT THIS TIME. (Check If Appropriate) PLEASE SIGN THE ABOVE AND FORWARD PROMPTLY. USE OTHER SIDE OF THE FORM TO PROVIDE ADDITIONAL INFORMATION.

6 Where do I go? The Emergency Room? Or an Urgent Care Center? When you have a life-threatening situation, such as chest pain, or a sudden and severe pain, the emergency department of the nearest hospital is the only option. If you went to an urgent care clinic they would just send you on to the ER in an ambulance. But, if your condition is less serious but still requires immediate attention choosing an urgent care facility can save time and money. If you have a sprained ankle or an ear infection, you may end up waiting for many hours in the emergency room and paying hundreds of dollars. Most urgent care centers are open for extended hours and will be able to accommodate you more quickly. When you need to go to the Emergency Room: If you have a serious condition stroke, heart attack, severe bleeding, head injury or other major trauma go straight to the nearest ER. Don t take a chance with anything lifethreatening. The ER is the best place for these and other conditions including: Chest Pain Difficulty Breathing Severe Bleeding or Head Trauma Loss of Consciousness Sudden loss of Vision or Blurred Vision When an Urgent Care Center can better meet your needs. After Occupational Medicine/Primary Care Provider s business hours for treatment of: Minor burns or injuries Sprains and strains Allergic Reactions (non life-threatening) Rash or other skin irritations Animal Bites Broken Bones When In doubt, call ahead. If the urgent care clinic can t accommodate your condition they will advise you to go to the nearest emergency facility. Report your claim to QualCare, Inc. by calling

7 QUALCARE, INC. WORKERS' COMPENSATION CLAIM TRANSMITTAL FORM TO: QualCare, Inc. 100 Decadon Drive Egg Harbor Township, NJ PHONE: FA NUMBER: (Only for Workers' Compensation ) NUMBER OF PAGES SENT (#) FROM: (Name of Claim Coordinator) (Name of District) This is a: New Claim Additional Information on Existing Claim (Claim Number, if known) Date of Loss: Claimant Name: Always complete this form whenever transmitting Workers' Compensation Claims to QualCare

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9 FIRST ACCIDENT REPORT CONFIRMATION (FARC) Record Only QUALCARE NOTIFIED ON CASE MANAGER Qual-Lynx QUALCARE INJURY DATE REOPEN DATE 02/08/2011 I/ TIME 12:00:00AM CLAIM NUMBER CLAIMANT SSN DATE OF BIRTH 12/10/1985 AGE 27 NAME TEST SAMPLE MARITAL STATUS GENDER M ADDRESS 123 NO NAME ST DAYS WORKED EMPLOYMENT.....,.: EGG HARBOR TOWNSHIP, NJ SALARY STATUS FT JOB TITLE SHIFT HOME PHONE PAYMENT CELL PHONE FREQUENCY EMPLOYER ACCAS EGG HARBOR TWP BOE PHONE FA LOCATION ADDRESS 13 SWIFT DRIVE CONTACT SUSAN DIEFENBECK CITY, STATE, ZIP EGG HARBOR TOWNSHIP, NJ DATE EMPLOYER NOTIFIED REPORTED BY RECEIVED VIA PHONE WITNESS NATURE OF INJURY PART OF BODY AFFECTED LOCATION OF ACCIDENT AGENT HOW INJURY OCCURRED DOMINANT HAND PREVIOUS MEDICAL CONDITION PREVIOUS WORKERS' COMP INJURY PRIMARY CARE PHARMACY TREATMENT DIRECTED TO TREATMENT DIRECTED BY COMMENTS UNKNOWN NOT REPORTED NOT REPORTED NA NA TEACHER SALARY TYPE 12 MONTH CHILD INVOLVED NO AGE OF CHILD SPECIAL NEEDS CHILD PREPARED BY AnnaMarie Finnegan DATE PRINTED 07/13/2012 2:08:36PM DATE PREPARED 42 MF.D l-isp WC. PAR. m1 WC First Accident Renort Pa!!c I of I

10 This form is generated by QualCare ACCAS EGG HARBOR TWP BOE 13 SWIFT DRIVE EGG HARBOR TOWNSHIP, NJ NJ /08/ /31/9999 QualCare, Inc. 30 Knightsbridge Road Piscataway, NJ ACCAS SAMPLE, TEST 12/10/ NJ 123 NO NAME ST EGG HARBOR TOWNSHIP, NJ M Full-Time 02/08/2011 SUSAN DIEFENBECK ,, AnnaMarie Finnegan

11 QUALCARE Fax: (609) URGENT: PLEASE FA COMPLETED FORM WITHIN 24 HOURS AFTER EACH VISIT. DUTY DETERMINATION INSTRUCTIONS EMPLOYEE: QC CLAIM #: DATE OF INJURY: EMPLOYER: JOB TITLE: BODY PART(S) INJURED: GROUP: CONTACT: [Case Manager] DATE OF VISIT: PHONE: (609) AUTHORIZATION: INDICATE LEVEL OF PHYSICAL ACTIVITY LEVEL OF FUNCTION: INDICATE RESTRICTIONS BELOW IF THEY APPLY TO INJURY: May return to work. No restrictions of job activities required. In an 8 hour day, employee may: Concurrent therapy may be required, but all essential job STAND / WALK SIT functions may be performed safely and without harm to employee. 1-4 hours 1-3 hours 4-6 hours 3-5 hours May return to work with restrictions. 6-8 hours 5-8 hours May not return to work. Requires severe restrictions of physical DRIVE (if driving is part of job): HAND LIMITATIONS: activities that include bed rest and restrictions to home only. Cannot drive Single grasping Employee is allowed to go to doctor's office and therapy only. < an hour Pushing / pulling 1-3 hours Fine manipulation 3-5 hours INITIAL COMPLAINT: 5-8 hours D / ICD9: CAN EMPLOYEE DRIVE TO WORK IF YES NO ALTERNATE DUTY IS PROVIDED? CAUSALLY RELATED TO INJURY: YES NO VEHICLE TYPE EMPLOYEE MAY OPERATE PLEASE DESCRIBE ANY OTHER RESTRICTIONS THAT APPLY: LIFTING AND OTHER PHYSICAL RESTRICTIONS Foot pedals / repetitive use Reaching overhead Lifting or carrying Climbing more than less than lbs. one flight of stairs RESTRICTIONS ARE IN EFFECT UNTIL: TREATMENT PLAN Additional treatment and referrals require prior authorization. Prescription(s) must be faxed with this form. PT / OT: DIAGNOSTICS: SURGERY: PHYSICIAN: ADDRESS: Phone: FA: HAS EMPLOYEE ACHIEVED YES NO MAIMUM MEDICAL IMPROVEMENT? ANTICIPATED MAIMUM MEDICAL IMPROVEMENT DATE: EMPLOYEE WAS A NO SHOW FOR THIS APPOINTMENT NET APPOINTMENT DATE: PHYSICIAN'S SIGNATURE: CLAIMANT'S SIGNATURE: All medical bills related to this case will be paid according to QualCare's negotiated terms. SUBMIT ALL MEDICAL BILLS TO: Qual-Lynx 100 Decadon Dr. Egg Harbor Township, NJ 08234

12 C:\Documents and Settings\mollendike\Desktop\School Forms\Supervisor Report.docf:d\r\w\gcssdjif\forming\98-99\clmcoord\suprvisr.doc Supervisor Report Board of Education Please Circle: Vehicular Accident Non-Vehicular Accident Police Report Attached Name of Injured Date/Time of Injury Occupation Dept. Date of Hire Nature of Injury Entity Vehicle Description of Damage Location of Accident 1. What job was employee doing including tools, machine, materials or vehicle used? 2. How was employee injured? 3. What improvements should be made with method, procedure or injured s performance? 4. What was defective or in an unsafe condition? 5. If equipment, etc., was involved, where is equipment now? Please store any involved equipment for inspection purposes. 6. What equipment should be used? 7. What steps were taken to prevent similar injuries? Supervisor s Name Title: Date of Report:

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14 The Communication Process Injured Employee District/Employer Physician Positive Communication Claim Administrator Managed Care Nurse

15 What Are Their Responsibilities? Injured Employee: - promptly report injury - provide a complete description - get better Physician: - see injured employees promptly - determine if injury is work related - prescribe treatment - monitor patient progress - communicate with all players - make return to work decisions! Managed Care Nurse - manage medical progress - speed up medical processes - work to get injured employee back to full health as soon as possible - communicate with all players Employer: - create internal reporting policy and procedure - ensure its enforcement and communication - monitor incident and claim activity - investigate accidents - communicate with all players - NJ is one of only 12 states which allow employer-directed medical care! Claim Administrator: - set up claim file - determine compensability within the statute - monitor activity for breaches of the statute - pay claims as appropriate - manage file through litigation - communicate with all players

16 Injured Employee Follows local procedures to report claim Accident Investigation Report is sent to Safety Director and Qual-Lynx Supervisor Completes Accident Investigation Report Claims Coordinator Calls QualCare using FAR as a guide Claims Coordinator Directs injured employee to primary care MD Qual-Lynx receives overnight transmission of claim QualCare takes claim and enters it into Qual- Care system *QualCare assigns claim to Medical Case Coordinator MD issues DDI to QualCare and Claims Coordinator after every visit Qual-Lynx contacts Employee, MD, and Employer to gather claim info QualCare issues FARC and FROI to Claims Coordinator with QC Claims Number QualCare contacts Employee, MD, and Employer to gather additional info Qual-Lynx issues FROI to municipality and to State *QualCare assigns Nurse Case Manager where required Qual-Lynx issues claims acknowledgement to municipality * Medical Case Coordinator is assigned to every case. * Nurse Case Manager is assigned to more difficult cases.