Multi-state claims services

Transcription

1 workers compensation Multi-state claims services Welcome to SFM, your workers compensation insurer. Important information for SFM policyholders with business locations outside Minnesota, Iowa, Nebraska, South Dakota and Wisconsin. Please forward to the persons at those other-state locations who deal with work injuries. To report a work injury that occurred outside a Minnesota, Iowa, Nebraska, South Dakota or Wisconsin location Report the injury right away. Have the injured employee call the SFM Work Injury Hotline at (855) along with his or her supervisor. The injured worker will get the chance to speak with a specially trained nurse who can provide a treatment recommendation, and the claim will automatically be reported to SFM. OR Report online at sfmic.com. If you are reporting online at you ll need your organization s SFM policy number. You should be able to get that from someone in your finance department, or from the person in your home office who reports work injuries. Even if you don t have all the information, report the injury right away anyway. You will be sent a letter promptly acknowledging that the claim has been received. If you don t receive an acknowledgement within a week, please call SFM at (800) ext 4265 or 4250.

2 Getting prescriptions filled Injured employees who seek medical attention should be given one of the attached First fill prescription program sheets and attached cards. This temporary card allows employees to fill the first workinjury related prescriptions without any out-of-pocket costs. SFM will send longer-term replacement cards to injured employees within a week of receiving the First Report. Medical provider network Recommended provider networks assure you of receiving (1) quality medical care focused on the employee s work abilities and (2) negotiated lower charges. These can help your organization control its workers compensation premium. For a recommendation on the medical network in your region that can provide the best outcomes for you, call your Gallagher Bassett servicing office. Who will be handling your claims SFM has engaged Gallagher Bassett Services Inc. for claims management services outside Minnesota, Iowa, Nebraska, South Dakota and Wisconsin. After you ve reported a claimed work injury, you and your injured employee may be contacted by a Gallagher claims representative during the handling of the claim. If you have questions about a claim Call your Gallagher Bassett claims servicing branch office. Attached is a directory of Gallagher Bassett offices in various states. Use this to find the office serving you. For general questions, call SFM at (800) ext 4265 or If you receive a bill from a medical provider Send it promptly to: Gallagher Bassett Services Inc. P.O. Box Tucson, AZ Include accompanying medical reports with the medical bill. If you don t have the medical report, be sure to send the bill anyway. Additional resources SFM makes dozens of educational resources available to you as a policyholder. They cover preventing injuries, handling injured employees and many other workers compensation topics. Includes posters and other ready-to-use materials. Order or download them through SFM s Resource catalog at SFM Companies 3500 American Blvd. West, Suite 700 Bloomington, Minnesota SFM Mutual Insurance Company ph

3 revised 07/15 Directory of regional claims offices If you have questions about a claim, call your Gallagher Bassett claims serving branch office ARIZONA Gallagher Bassett Services 007 P.O. Box Scottsdale, AZ N Scottsdale Road, Suite 240 Scottsdale, AZ Phone: (480) Fax: (480) Toll-free: (800) Bruce Martin, Branch Manager bruce_martin@gbtpa.com COLORADO Gallagher Bassett Services 029 P.O. Box 4068 Englewood, CO S. Fiddlers Green Circle, Suite 250 Greenwood Village, CO Phone: (303) Fax: (303) Toll-free: (800) Cynthia Tucker, Branch Manager cynthia_tucker@gbtpa.com FLORIDA Gallagher Bassett Services SW 149th Avenue, Suite 200 Miramar, FL Phone: 954/ Fax: 866/ Toll-free: (800) Andrea Humphries, Branch Manager andrea_humphries@gbtpa.com ILLINOIS Gallagher Bassett Services 151 P.O. Box 8009 Itasca, IL W. Golf Road, 9th Floor Rolling Meadows, IL Phone: (847) Toll Free: (800) David Langan, Branch Manager David_Langan@gbtpa.com INDIANA Gallagher Bassett Services Nimtz Parkway, Suite 100 South Bend, IN Phone: (574) Fax: (574) Toll Free: 800/ Marge Rzepka, Branch Manager Marge_Rzepka@gbtpa.com KANSAS MISSOURI Gallagher Bassett Services East 104th Street, Suite 200 Kansas City, MO Phone: (816) Fax: (816) Toll-free: (800) Stacy Goble, Branch Manager Stacy_Goble@gbtpa.com MICHIGAN Gallagher Bassett Services 002 (Lansing) Arbor Glen Office Park 300 W Lake Lansing Rd East Lansing, MI Phone: (517) Fax: (517) Toll Free: (800) David Langan, Branch Manager David_Langan@gbtpa.com MONTANA Gallagher Bassett 080 (Missoula) 2501 Catlin Street, Suite 200 Missoula, MT Phone: (855) Fax: (406) Regina Pearson, Branch Manager Regina_Pearson@gbtpa.com NEVADA Gallagher Bassett Services 156 P.O. Box Las Vegas, NV E. Flamingo Road, Suite 314 Las Vegas, NV Phone: (702) Toll Free: (866) Fax: (866) Charles Rostad, Branch Manager Charles_Rostad@gbtpa.com OKLAHOMA Gallagher Bassett Services Waterford Blvd., Suite 120 Oklahoma City, OK Phone: (405) Fax: (405) Toll-free: (800) Stacy Goble, Branch Manager Stacy_Goble@gbtpa.com All medical bills and notes are sent to: Gallagher Bassett Services P.O. Box Tucson, AZ SFM Companies 3500 American Blvd. West, Suite 700 Bloomington, Minnesota SFM Mutual Insurance Company ph

4 First Fill Prescription Program First Script offers a fully integrated First Fill program that provides complete control of pharmacy services throughout the life of the claim. Our First Fill program offers no out-of-pocket expense for the injured worker and no financial risk to the payer. First Script takes on the liability for payment of the medication should the claim prove to be non-compensable. How Our First Fill Program Works When utilizing our First Fill program, the injured worker is given First Script information to take with their prescriptions to the pharmacy. This information could be in the form of a preprinted prescription card, employer information form, or simply a toll-free phone number. At the pharmacy, the pharmacist calls First Script to verify eligibility, and temporarily enrolls the injured worker. No calls are made to the employer for authorization, and the approved injured worker receives his or her prescription at no out-ofpocket expense. The pharmacist bills First Script and First Script bills the payer in accordance with our agreement. Our Network The First Script pharmacy network includes more than 67,000 pharmacies, including all of the major drug stores, mass retailers, and grocery store chains. To locate a pharmacy, the injured worker can contact or visit agreement. First Fill Program Benefits Our First Fill program allows injured workers to receive medications in the most expedient manner at no cost to them First Script assumes the financial risk until the claim is deemed compensable The program offers flexible options for injured workers to receive their initial prescriptions First Script works hand-in-hand with claims managers to define the best program options First Fill scripts are processed online against specified plan parameters Partial Network List Leveraging Coventry s integrated systems, product suite and data warehouse, we are able to deliver a fully integrated program unmatched in service workflow, decision support, and outcome analysis Coventry Health Care Workers Compensation, Inc. All rights reserved. A&P Albertson s Arrow BJ s Bartell Drug Bi-Mart Brooks/Maxi Brookshire Buttrey Costco Cub Pharmacies CVS Dillon Stores Dominick s Drug Emporium Duane Reade Eckerd Drug Fred s Inc. Fred Meyer Fry s Food Stores Furr s Genovese Giant Eagle Grand Union Happy Harry s Harco H.E. Butt Health Mart Hy-Vee/Drug Town K&B K Mart Kerr Drug King Soopers Kroger Pharmacies Leader Drug Long s Medicap Medicine Shoppe Meijer Pharmacies Neighbor Care Osco Pathmark Phar Mor Price Club Publix Raleys Randall s Rite Aid Rx Plus Safeway Sam s Club Sav-On Schnuck s ShopKo Shoprite Smith s Food & Drug Snyder Stop & Shop Super D Target Stores Thrifty Payless Tom Thumb Von s Walgreens Wal-Mart Wegman s Weis Pharmacies Winn Dixie

5 Employee Information Form Workers Compensation Prescription Drug Program First Script, in conjunction with your employer, offers the finest in pharmacy benefit management programs designed specifically for workers compensation. Our nationwide pharmacy network and superior customer service make our pharmacy program more convenient than any other. Injured workers can fill their prescriptions at more than 67,000 retail pharmacy locations, which includes all major drug, mass retail and grocery store chains, plus 97% of local independent pharmacies with no out-ofpocket expense. Partial List of Participating First Script Pharmacies A&P Accredo Health Group Accredo Therapeutics Albertsons Albertsons Sav-on Arbor Aurora B&B Baker's Bartell Drugs Bashas United Drug Bel Air Bel Air Bi-Lo Foods Bi-Lo, LLC Bi-Mart Big Y Bilo/Riverside BioScrip Bloom Brooks Brookshire Brothers Brookshire Bruno's Budget Chopper CVS Carrs Quality Center Cash Wise Clinic Cash Wise Central Market City Market Clinic Coborn's Collegeville Coborn's Long Term Care Coborn's Cost Cutters Costco Cub D & W Market Dillons Discount Drug Mart Doc's Drugs Dominick s Drug Barn Drug Emporium Drug Fair Drug Mart Drug Town Drug Warehouse Duane Reade Eaton Apothecary Eckerd Drugs Econo Foods Fairview Family Fare Farm Fresh Felpausch Food 4 Less Food City Food City United Drug Food Lion Food Pyramid Food World Fred Meyer Fred s Inc. Fred's Fred's Xpress Fruth, Inc. Fry s Food & Drug Genuardi's Gerbes Giant Eagle Giant Glen's Markets Grandview Medical H-E-B H-E-B Plus Haggen Food & Hannaford Happy Harry s Harps Harris Teeter Health Mart Hen House Hi-School Highpoint Homeland House Calls Hy-Vee Ike's Ingles Island Drug JayC Jewel-OSCO KD, Inc. KLM, Inc. Kaiser Permanente Kash n' Karry Kerr Drug Kessel King Soopers King's Kinney Drugs Kmart Kerr Drug King Soopers Knight Drugs, Inc. Kroger Lewis Drug Livingston Medical Long s Drugs Marc's Marsh Martin's May's Drug Med-X Drug Stores Medicap Medicine Shoppe Mediserv Meijer Mendota Healthcare Mercy East Mercy Mall Mercy Walworth Mercy West Mercy Woodstock Mi Tienda Milton Minyard More 4 Family Mr. Z's Navarro Discount Neighbor Care Nob Hill Olympic Drug Oncology Rx Care Advantage Osco Drug Owsley Prescription Center P & C Food Market & Pamida Pantry Pathmark PayLess Drug Stores Center Pharmerica Pick N Save Piggly Wiggly Powell Prescription Center Price Chopper Price Cutter Price Wise Professional Services Publix Super Markets, Inc. QFC QSI, Inc. Quality Markets Rainbow Raley s Raley's Ralphs Ramey Randalls Reasor's Food & Reasor's Grocery Reasor's Reasor's Supermarkets Recept Rite Aid Rogers Rosauers S-mart Foods Sack 'n Save Safeway Sak 'N Save Sam s Club Sartoris Super Drugs Sav-On Save Mart Supermarkets SaveRite Schnuck s Scolari's Scot's Lo-Cost ShopKo ShopRite Smith's Food & Drug Stores Smitty's Snyders Drug Store Stop & Shop Strand Stufflebeon Sun Mart Super 1 Super D Drug Store Super Fresh Super G Discount Drug Super Rx Sweetbay Supermarkets Target Stores Thrifty White Times Times Supermarket Top Food & Drug Tom Thumb US Oncology USA Drug United Village Apothecary Vons Waldbaum's Walgreens Wal-Mart Wegmans Weis West Broad Medical Western NM Medical Group White Drug Winn-Dixie Wolfe Prescription Center Xpect Once your examiner determines you have a compensable claim, a First Script ID card will be mailed to you. Please note that First Script is valid only for medications prescribed to treat your work-related injury. If after using your First Script prescription card you switch to a different pharmacy for your workers compensation prescriptions, please call First Script Customer Service at with your new pharmacy name and phone number Coventry Health Care Workers Compensation, Inc. All rights reserved.

6 PRESCRIPTION PROGRAM FOR WORK-RELATED INJURIES Welcome to First Script, a pharmacy benefit program designed exclusively for SFM Mutual Insurance Co., #002989, in partnership with Gallagher Bassett Services, Inc. for your workplace injury. Injured Worker No Cost STEP 1 STEP 2 STEP 3 Complete the information requested in the bottom portion below. Call First Script at to enroll, and receive your required Member ID. 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 68,000 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. The workers compensation carrier will determine the compensability of the claim. Instructions The injured worker s employer participates in First Script, a pharmacy benefit program administered by ESI/Medco. Call the First Script Help Desk, 24 hours a day, 7 days a week, at If the Member ID number is not listed on this form, please provide the claimant information indicated below to receive the Member ID #. Please note the ID number on the form and return to injured worker. First Script claims are submitted electronically and electronic approval of the claim will be returned. : You will not be required to submit any paperwork for this claim and payment is guaranteed for all electronically accepted claims. : At the request of the workers' compensation carrier for this customer, please use the following information to process all workers' compensation prescriptions online. Name: SSN (Last 4 digits): XXX-XX- Date of birth: / / State where injury occurred: Date of injury: / / Member ID: (Member ID # is generated at time of enrollment) RX PROGRAM ADMINISTERED BY: ESI/Medco GROUP NUMBER: FSNCVTY BIN NUMBER: Client #: Employer Name: SFM Mutual Insurance Co. (Above information to be completed by injured worker or supervisor)

7 Programa de Beneficio Farmacéutico Para Accidentes Laborales Bienvenido a First Script, un programa diseñado exclusivamente para SFM Mutual Insurance Co., #002989, en asociación con Gallagher Bassett Services, Inc. para su lesión relacionada con su trabajo. Empleado Lastimado Ningún Costo Paso #1 Paso #2 Paso #3 Complete la información requerida en el formulario de la parte inferior. Llame primero a First Script para inscribirse donde le proporcionarán un número de identificación. Presente esta forma a su farmacéutico con su receta relacionada a su accidente o lesión. Sin Tardanza/ Sin Demora Siéntase Mejor Mas Rápido First Script esta disponible en más de 68,000 farmacias en todo el país. Para localizar una farmacia cerca de usted, favor de llamar al departamento de servicios de First Script al First Script es solo valido para medicinas recetadas en el tratamiento de su lesión que sea directamente relacionada o por causa de su trabajo. Usted o su grupo de seguro medico son responsables por cualquier otra receta. El seguro de compensación de su trabajo determinará la compensación de su caso. Instructions The injured worker s employer participates in First Script, a pharmacy benefit program administered by ESI/Medco. Call the First Script Help Desk, 24 hours a day, 7 days a week, at If the Member ID number is not listed on this form, please provide the claimant information indicated below to receive the Member ID #. Please note the ID number on the form and return to injured worker. First Script claims are submitted electronically and electronic approval of the claim will be returned. : You will not be required to submit any paperwork for this claim and payment is guaranteed for all electronically accepted claims. : At the request of the workers' compensation carrier for this customer, please use the following information to process all workers' compensation prescriptions online. Name: SSN (Last 4 digits): XXX-XX- Date of birth: / / State where injury occurred: Date of injury: / / Member ID: (Member ID # is generated at time of enrollment) RX PROGRAM ADMINISTERED BY: ESI/Medco GROUP NUMBER: FSNCVTY BIN NUMBER: Client #: Employer Name: SFM Mutual Insurance Co. (Above information to be completed by injured worker or supervisor)