1 Workers Compensation Claims Kit for YMCAs Thank you for placing your workers compensation coverage through The Redwoods Group. It is our privilege to assist you in this vital area of your organization. Like you, we are as concerned with the health and safety of YMCA staff as we are members. Our goal is to partner with you to provide a culture of safety for your staff and to provide excellent medical care for those that have been injured to enable them to return to their mission-focused work. There are three things to focus on to keep staff safe and on the job: Continuously improve the work environment Prevent common injuries Get injured workers cared for and back to work quickly We will apply our Y-specific risk management expertise to identify and address common exposures to improve workplace safety and reduce injuries. Redwoods proactive, service-oriented workers compensation initiatives also ensure quality claims management and timely medical care for injured employees. As in all aspects of our business, Redwoods has full accountability for the claims process. To enhance this vital service, we have partnered with Cambridge Integrated Services, Inc., a leading workers compensation claim administrator, to assist us in the day-to-day claim handling functions in your state, under our guidelines and direction. Our in-house Case Management Specialist, Angela McGarity, BSN, RN, CRRN, is your first point of contact at Redwoods for workers compensation claims. She will assess the injury, be integrally involved in lost time cases and work with all parties to ensure your injured employees remain in or return to the workplace as quickly as possible. In order to provide your injured employees with prompt service, care and the empathy they deserve, we need you to immediately report all claims directly to us. This package contains important workers compensation claim reporting information, a Supervisor Incident Report and checklists for both you and your injured employee to complete in the event of a workers compensation claim. These tools will help you to file your claim quickly, with close attention to all claims considerations. The checklists will allow you to assist us in identifying and maximizing any cost-saving opportunities that may exist. We have also included information on our prescription drug program, which allows your injured employees to conveniently fill prescriptions for work-related injuries. If you need further information or have any questions concerning the claims process, risk management or your workers compensation needs, please don t hesitate to call us at Sincerely, Kevin A. Trapani President and CEO
2 Workers Compensation Claim Reporting Checklist for YMCAs 1. Address the immediate medical needs of your injured employee. 2. If any injury occurs to one of your employees, notify us immediately. Do not delay reporting the claim if certain information is not readily available. Please remember to contact us even when your injured employee will not require immediate medical treatment. Late reporting may result in state-imposed fines. Please send a completed First Report of Injury (FROI) / First Notice of Loss (FNOL) via fax to or to You can also call us during normal business hours (8:30am 5:00pm EST) at and ask the operator to direct you to the Workers Compensation Team. If you need to reach us after hours or on weekends, please call our EMERGENCY HOTLINE at Examples of emergencies are: death severe injury incidents involving more than one employee 3. Provide your injured employee with a copy of the First Script Employer Information Form or a temporary. The form or card will allow your injured employee to receive an initial supply of prescribed medication. 4. Have your injured employee s supervisor complete the enclosed Supervisor Incident Report. Be sure to secure the names, addresses, and phone numbers of witnesses to the incident. 5. Set aside any materials, equipment or machinery that may have contributed to or caused the injury. Secure the name, address, and phone number of anyone you feel may be responsible for the injury. 6. If you believe the injury will prevent the injured staff member from performing his or her regular duties, please begin to identify Y-related work he or she could return to on a light-duty or full-time basis. The Redwoods Group Case Management Specialist or the claim adjuster may contact you to obtain additional information concerning the claim.
3 Injured Employee Claim Reporting Checklist 1. If necessary, seek immediate medical attention for your injuries. Notify your supervisor if you feel your injuries were caused by your job duties, even if you do not plan to seek immediate medical treatment. 2. Help the YMCA secure the full names of any witnesses to your incident and to identify any materials, equipment or machinery that you feel may have contributed to or caused your injury. 3. Provide the YMCA with the names and addresses of any medical providers that have provided treatment for your injuries. 4. Request that the YMCA immediately report your injury to The Redwoods Group. 5. The Redwoods Group Case Management Specialist or the claim adjuster will contact you to obtain additional information that may be needed to complete the investigation of your claim. You may contact The Redwoods Group at any time with questions regarding your claim: The Redwoods Group 2801 Slater Road, Suite 110 Morrisville, NC Phone: , ext Fax: Promptly complete and return any forms that you receive from your claim adjuster. These forms can be returned in the postage-paid envelope that you will receive with the forms. 7. Please contact your claim adjuster immediately following every appointment. This will help us expedite payment of any medical bills related to your claim.
4 Workers Compensation: Supervisor Incident Report Page 1 of 2 Important: The supervisor should complete this form immediately after the incident. Additional forms available at Injured employee name: Male Female Social Security number: - - Date of birth: / / Home address: Phone: Date of hire: / / Job title and department: Date of injury: / / Time of injury: AM PM Was first aid provided onsite? Yes No Was additional medical attention sought? Yes No (If applicable) Name of facility or physician that provided treatment: Was, or will there be, a drug screen completed? Yes No Last day worked: / / Return-to-work date: / / Scheduled workweek at time of injury Hours: Days per week: Start time: End time: Injured employee normal/usual schedule Hours: Days per week: Start time: End time: Witnesses to the incident Name: Address: Phone: Name: Address: Phone: Name: Address: Phone: Injured employee statement regarding the injury (list all circumstances and equipment involved): Part(s) of body affected: Type of injury or injuries: The answers I have provided to the above questions are true to the best of my knowledge. Injured employee signature: Date: / / Supervisor signature: Date: / / Please complete page 2 of this form (over)
5 Supervisor Incident Report (cont.) Page 2 of 2 Please check one and only one box in each of the following sections: SPECIFIC LOCATION OF INCIDENT Aquatics area Athletic / play field Cabin / tent Campfire / meeting area Challenge course Child watch / babysitting Childcare area Class / meeting room Climbing wall / tower Ex Room: aerobics, etc. Ex Room: cardio / strength equip Ex Room: free weights Gym Gymnastics facility Lobby / halls Locker / rest room Parking lot / garage Play structure or area: interior Playground (with equipment) Pool Racquetball (etc.) court Range: rifle / archery Residence facility Running track Skating rink Spa / Sauna / Steam Stairs Waterfront (non-pool) PROGRAM NAME Aquatics Camp: Day / Holiday Camp: Resident Camp: Sports Childcare: Before & After Childcare: Child Watch Childcare: Outdoor Education Childcare: Preschool / Daycare Health & Fitness: Organized Health & Fitness: Personal Non-sport activities Senior program / activity Social Outreach (incl. residence) Special Events / Field Trips Sports: Adult Sports: Informal Sports: Youth GENERAL ACTIVITY Aquatics: boating, all forms Aquatics: all others Animal: grooming Animal: care Animal: training Baseball / Softball / T-ball Basketball Bicycles / Motorbikes Class: Aerobics Class: Kick-boxing Class: Martial arts Dance Exercise: Cardio equip. Exercise: Free weights Exercise: Strength equip. Exercise: Run / Walk Exercise: personal Football Games / Structured activity Gymnastics Hiking / backpacking Hockey (ice or roller) Horseback riding Playground equipment Racquetball / Handball / Squash Skateboarding Skating (ice or roller) Skiing / Snowboarding Skiing / Water Soccer Transportation / Driving Volleyball / Walleyball Walking (incidental) SPECIFIC ACTION Aggressive behavior of / by Caught in, by, or between Contact with / exposure to Exertion SOURCE OF INJURY Aquatics facility: deck / dock Aquatics facility: equipment Aquatics facility: sides / bottom Aquatics facility: body of water Blood / body fluids Fall (from, onto, into, or against) Horseplay Inhale / ingest Participation / playing Door Environment: sun, heat, etc. Equipment: playground Floor / Ground Furniture Insect / animal Locker / cabinet Object (ball / bat / toy / etc.) Person (another) Self Pushed / pulled / bumped Struck by / against Wall / vertical surface APPARENT INJURY Abrasion / Scratch Amputation Aquatic distress Bite / Sting Breathing shortened / Impaired Bruise / Contusion Burn / Blister Chemical Exposure Cramp Cumulative Trauma. Dislocation Dizziness / Unconscious Fracture / Break Irritation / Reaction Jam Laceration / Cut Pain / Soreness Pinch / Crush Puncture Seizure / Dysfunction Sprain / Strain Stress / Mind / Psyche No visible / Apparent injury BODY PART please check if applicable right left upper lower Arm Hand Wrist Elbow Finger Leg Foot Ankle Knee Toe Shoulder Chest Stomach Side Back Buttocks Hip Groin Face Ear Eye Nose Head Neck Heart Lungs Mouth / Lips Mind / Psyche Teeth None / Not applicable
6 Preferred Medical Providers In Your Area In order to provide consistent, optimal care and control medical expenses, Redwoods suggests the use of preferred medical providers. Following are some of the medical providers who have agreed to work with us for the treatment of your injured employees. For a complete listing of preferred medical providers in your area, please contact Redwoods at ext. 457, or (Will list providers in the Y s area: primary care office, urgent care facility, hospital)
7 Workers Compensation Phone and List Company Address: The Redwoods Group 2801 Slater Road Suite 110 Morrisville, NC Company Phone: Main Office Line WC Claims Fax Line After Hours Emergency Hotline Primary Contact: Angela McGarity Case Management Specialist Additional Contacts: David Hall Vice President Claims Administration Donna Grier Workers Compensation Product Manager James Fryling Senior Vice President Claims/ General Counsel
8 Work Related Injury Prescription Drug Program The Redwoods Group has selected The First Script Network Services to administer its prescription drug program for your injured staff members. First Script offers the finest in pharmacy benefit management programs designed for work related injuries and is specifically tailored for implementing at the employer level. The program allows injured employees to conveniently fill prescriptions for workrelated injuries at more than 61,000 retail pharmacy locations nationwide. When you receive notice of an employee injury requiring medical treatment, simply either; 1) complete the bottom portion of the Employer Information Form included in this kit and present it to your injured employee; or 2) complete one of the enclosed tear-off Pharmacy Benefits Cards for the employee. YMCA Benefits Injured employees are automatically eligible to use the program with no required employer action other than to provide employees with First Script information Using the program produces significant prescription cost savings First Script contains overall pharmacy costs through appropriate utilization control and network penetration First Script fully integrates with the managed care services provider to offer a comprehensive program that ensures the best possible outcome for both the injured staff member and the YMCA Injured employees can also receive their prescriptions by mail Claimant Benefits The program requires no out-of-pocket expense, paperwork, or need for prescription cost reimbursement for the injured staff member The pharmacy network includes over 61,000 pharmacies, so injured staff can most likely use their preferred pharmacy The First Fill Program First Script offers a fully integrated first fill program that provides complete control of pharmacy services throughout the life of the claim. The first fill program offers no out-ofpocket expense for the injured employee. How First Script Works Simply provide your injured staff with a First Script Prescription Card or Employer Information Form to take to the pharmacy with their prescriptions. The pharmacist calls First Script and eligible employees are temporarily enrolled. No authorization calls are made to you, and the injured employee receives their prescriptions immediately at no cost. The pharmacy bills First Script for the prescription. The First Script Formulary The First Script formulary, designed by a team of registered pharmacists, sensitively balances your injured staff member s need for convenience with your need to control costs. The formulary anticipates and manages drug use proactively by applying a comprehensive set of drug utilization review (DUR) controls prior to dispensing.
9 Employer Information Form PRESCRIPTION PROGRAM FOR WORK-RELATED INJURIES Injured Worker No Cost STEP 1 STEP 2 To obtain your First Fill prescriptions complete the information requested in the bottom portion below Present this form to your pharmacist along with the prescriptions for your work-related injury. No Delay Feel Better Faster First Script is available at over 61,000 pharmacies nationwide. To locate a nearby pharmacy, please call First Script Customer Service at Please note that First Script is valid only for medications prescribed to treat your compensable work-related injury. You or your group health insurer, are financially responsible for any other prescriptions. Pharmacy Instructions The inj ured worker s employer participates in First Script, a pharmacy benefit program administered by Caremark. Call the First Script Help Desk, 24 hours a day, 7 days a week, at to verify employee eligibility, and receive Member ID #. First Script claims are submitted electronically and electronic approval of the claim will be returned. Pharmacy: You will not be required to submit any paperwork for this claim and payment is guaranteed for all electronically accepted claims. First Script Help Desk Pharmacy: At the request of The Redwoods Group, please use the following information to process all workers' compensation prescriptions online. : : / / SSN: - - Employer Name: (Above information to be completed by employee or supervisor.) RX PROGRAM ADMINISTERED BY: Caremark GROUP NUMBER: BIN NUMBER: PCN #: TDI Member ID:
10 Do you have questions about First Script? Do you need more Prescription Cards? Please call First Script at INSTRUCTIONS FOR USE: When an employee is injured on the job: 1. Tear off one of the Prescription Cards to the right. 2. Tell the employee to present this card and their prescriptions to their pharmacist.
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