POLICYHOLDER CONTACT GUIDE

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1 POLICYHOLDER CONTACT GUIDE REPORT AN INJURY PHONE (866) FAX (321) Please copy on the First Report your ECM Solutions Claim Advocate Tammy Burgess Renee Lanier Wanda Jackson SUBMIT MEDICAL BILLS & RELATED MEDICAL NOTES TO: MCMC P.O. BOX 1160 CANONSBURG, PA FAX (724) To expedite the processing, please include the claim #, employee s SS#, date of injury and employer name. ADJUSTER & ADDITIONAL CLAIM DOCUMENTS: SOUTHEAST REGION P.O Charlotte, NC Phone: (888) NURSE CASE MANAGEMENT & PROVIDER RELATIONS (866) SUBROGATION (954) SIU & FRAUD HOTLINE (877)

2 Patriot appreciates the confidence you have placed in our workers' compensation program. Through our network of affiliate and contract providers, we are committed to providing you with efficient service that delivers quality medical care, controls costs, and facilitates returning employees to work in a prompt, safe manner. We emphasize: Prompt Reporting of injuries. Accidents should be reported within 24 hours. Claims Administration that provides adjusting and administrative services that meet state workers' compensation rules and regulations. Case Management that coordinates and monitors injured workers' medical care throughout the recovery process to promote an appropriate return to work. Bill Review that ensures compliance with state fee schedules prevents duplicate submissions and compares charges to treatment received. Provider Panel usage. In some cases Provider Panels may come under separate cover from our Claims Client Services Department. When an Injury Occurs... We urge you to report the injury as soon as it happens. Intake specialists are available 24 hours a day, seven days a week to take your injury report and if necessary, direct your injured worker to the nearest PPO provider. Acknowledgment of your phone call will be faxed to you. A copy of the completed state First Report of Injury form will be faxed, mailed, or ed to you upon request. Refer to the Policyholder Contact Guide for specific phone, fax and options. FOR SERIOUS ACCIDENTS, PLEASE ALSO CALL ONE OF OUR REGIONAL OFFICES IMMEDIATELY Included in your Welcome Packet... First Report of Injury - Use this form should you prefer to fax or your report of injury instead of using the toll free injury hotline. Provider Information - Network medical provider information is listed according to your location and your specific state requirements. Authorization for Release of Medical Information - Please have your injured employee sign this form and fax it to the assigned adjuster or case manager. State-Specific Forms - If applicable, other forms required by your state's workers' compensation regulatory agency are included. If a posting notice is required in your state, it is included and must be posted in one or more conspicuous sites at your place of business.

3 CLAIM MANAGEMENT Frequently Asked Questions After an injury occurs, where should I send my injured employee for medical care? Your Welcome Packet includes a list of preferred providers for your area, and the hotline intake specialist may also direct you to the nearest network provider. Statutory regulations can limit the initial choice of treating medical providers. Call your Claims Adjuster for assistance in determining your jurisdiction's provider choice requirements. Will I receive an acknowledgment after reporting an injury? You will receive confirmation by mail that we have assigned a claim number and adjuster to your employee's injury. What roles do the Claims Adjuster and Nurse Case Manager play in administering the claim? The Claims Adjuster is a licensed professional who will investigate and determine compensability, administer benefits per statutory requirements, and oversee adjudication of claims when necessary. The Nurse Case Manager is a licensed healthcare professional that will work with the injured employee to coordinate medical care and communicate with the employer and the medical provider to facilitate a prompt, safe return to work. Nurse Case Managers and Claims Adjusters work together to provide claim resolution for injured employees. What should I do if a medical provider or pharmacy calls me? Refer them to the Claims Adjuster or Nurse Case Manager assigned to the case. Please refer to the Policyholder Contact Guide for your regional contact. Whom should I call regarding an injured employee's workers' compensation benefits? Contact your regional Claims Adjuster assigned to the case. What should I do if I receive a medical bill for treatment of an injured worker? Mail the bill with any related medical notes to us in care of our bill review partner, MCMC, at P.O. Box 1160, Canonsburg, PA or fax it to MCMC at (724) To expedite processing, please include the claim number, employee's Social Security Number, date of injury and employer name. Where should I send other documentation received, such as, work status notes, state correspondence pertaining to the claim, or injured workers' paid prescription receipts, etc.? Please mail additional claim documentation to your regional Claims Adjuster listed on the Policyholder Contact Guide. What if I have questions about my medical provider listing? Please contact our Provider Relations department listed on your contact guide.

4 Consent for Release of Medical Information I hereby authorize representatives of Patriot Risk Services to obtain and review copies of all medical records related to my workers' compensation injury. This pertinent information will be discussed with other professionals involved in my medical treatment and any institution that, through the "Workers' Compensation Program" or otherwise, is paying all or part of the cost associated with my medical care. Name of Employee Social Security Number Claim Number Telephone Number of Employee address Name of Employer Date of Injury Signature of Employee Date A PHOTOCOPY OR FACSIMILE COPY OF THIS AUTHORIZATION IS AS VALID AS THE ORIGINAL.

5 CLAIM INVESTIGATIONS SPECIAL INVESTIGATIONS UNIT (SIU) The SIU department provides timely and quality claims investigations for the purpose of providing detailed information to the claims staff regarding a reported workers' compensation claim. Providing timely detailed information will properly inform our claims staff so they can assist the injured worker in receiving quality medical care, as well as mitigate the costs of the claim. In order to provide this superior service to our claims staff, we ask our clients to report the workers' compensation injury immediately to our 24-hour toll free number, listed in your Policyholder Contact Guide. SIU CLAIMS INVESTIGATION PROCESS SIU may to go the area where the accident occurred in order to investigate the claim properly. SIU professionals and field investigators have been properly trained to conduct thorough on-site investigations. Below is a list of items that maybe required as a result of the accident. 1. A contact number of those for the accident scene 2. Location of where the accident occurred 3. A list of all witnesses and contact information 4. Please secure the accident area if possible, and save any evidence that might be important to the accident 5. Obtain names of any outside party, (i.e. OSHA, police, fire, paramedics, etc...), who may have responded to the accident area SIU will send a field investigator to the accident scene and properly investigate the scene after discussing with the claims department. Our SIU field investigator will contact the client to arrange a time to meet at the accident scene. In order to properly inform our client in advance, we have listed below the following items that the field investigator may request in order to conduct a thorough investigation. Photographs of accident scene Taking measurements, and other forensic investigative processes, (for example, taking samples, obtaining copy of machinery operating manual, etc...) Recorded statements of all witnesses, and the injured party Obtain copies of all safety reports, witness statements, or other investigative material created as a result of the accident Obtain copies of all maintenance records, if equipment was used Obtain copies of the injured worker's personnel file, and wage information Obtain copies of all training records Obtain copies of all safety procedures that were in place that pertain to this accident type Obtain potential subrogation information, (i.e. building lease information, etc.) Possession of equipment after consulting with the relevant adjuster

6 ANTI-FRAUD PROGRAM CORPORATE STATEMENT ON FRAUD It is our corporate policy, to detect and investigate internal and external suspected fraudulent insurance acts, increase the awareness of the impact of fraudulent insurance acts, and educate personnel in the methods of detecting and preventing insurance fraud. ANTI-FRAUD PROGRAM The components of our Anti-Fraud program include: Detection and investigation of insurance fraud Education and Training of both our claims staff and our clients on identifying fraud and cost containment strategies Referral of suspected fraudulent claims to the appropriate state agencies Compliance with statutory requirements for reporting anti-fraud activities DETECTION AND INVESTIGATION OF INSURANCE FRAUD "RED FLAG INDICATORS" The accident was not reported in a timely fashion by the injured worker The accident occurs just prior to a strike, job termination, layoff, or at the end of a project or the close of seasonal work There are no witnesses to the accident The accident occurs in an area where the employee does not normally work The accident is not the type that an employee should be involved in There are frequent difficulties in contacting the injured worker during his period of disability A "tip" is received concerning the activities of the injured worker while out on disability The injured worker refuses a diagnostic procedure that would confirm an injury or period of disability The injured worker's attorney and/or the treating physician are known to be involved with fraudulent claims The injured worker frequently changes physicians Disability is not substantiated by objective medical findings The injured worker has received a release to return to work, but then changes physicians or medical providers Fraud Posters are available upon request, and can be provided in multiple languages. To report insurance fraud, please contact our Fraud Hot-Line: (877)

7 SUBROGATION Subrogation is described as an insurance carrier's right to recover from a wrongdoer all sums paid to, or for, its policyholder". Virtually every state's workers' compensation subrogation scheme presupposes that a "third party" is liable for causing the injury or death. Exactly who and what qualifies as a "third party" varies by state as well as the statutes governing each individual state. The purpose of the statutes is to protect the carrier, reduce the burden on employers and to ensure that the party, whose negligence caused the loss, bears the ultimate burden for the loss. At Contego Recovery, LLC, subrogation is identified on the front end of the claim. Upon receipt of the First Report of Injury (FROI) the subrogation department reviews all for subrogation potential. Additionally, all department heads are reviewing FROIs. Contego Services Group, LLC can also provide a wide variety of loss control and specialized safety training programs for your company. Our proactive approaches can help your company improve your loss ratios while providing the latest information to enhance your existing work place safety programs. Once it has been determined that there is potential for recovery on the claim, the case is assigned to the Special Investigation Unit (SIU) to investigate and capture information to go forward with a successful subrogation case. During the course a field investigation, we ask our external customers to always save any evidence that might be crucial to the claimant's accident. If the client fails to save crucial evidence, then "spoilage of evidence" could have unfavorable ramifications against the external customer if the claim is litigated. It is very important that our clients properly preserve evidence, and notify the carrier that they are in possession of this evidence. The subrogation specialist will immediately place any and all involved parties on notice of the intent to subrogate and advise them of their duty to protect our lien. The subrogation specialist will place a 30, 60 and 90-day diary and thereafter another 90-day diary until the subrogation/lien has been resolved. The adjuster will keep the subrogation specialist advised of litigation, mediations, and when the claim is close to settlement or closure. Prior to settlement, on a case by case basis, the adjuster and the subrogation specialist will determine the approach to take with regard to what would be most beneficial for the insurance carrier and the policyholder. The majority of the workers' compensation claims will not be settled without or until the third party case has been resolved. Should you have any questions at any time regarding subrogation, please feel free to contact our subrogation department listed on your Policyholder Contact Guide or us at:

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