University of Virginia Facilities Management Department. Workers Compensation Packet

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1 University of Virginia Facilities Management Department Workers Compensation Packet Last Revised February 2013

2 Checklist for Workers Compensation Claims Report the accident to your supervisor immediately. Complete the accident report and submit to your supervisor. Failure to notify as soon as possible may result in denied claims. Select a physician from the panel offered by your employer. Complete the form and submit to your supervisor. Seek medical attention from the panel physician and submit any disability slips/doctor s notes to your supervisor and/or agency workers compensation coordinator. You must obtain a doctor s note for EACH visit. If your accident is an emergency, please seek medical treatment from the UVA Health System or Martha Jefferson emergency room. This is ONLY for the initial treatment. If a VSDP (Virginia Sickness and Disability Program) participant, call the VSDP provider (UNUM) immediately to report the injury if the disability if anticipated to exceed 7 calendar days. The toll free number is Communicate results of all medical appointments and return-to-work status with your supervisor and/or agency s workers compensation coordinator. Notify your supervisor of any return-to-work release and present your medical release to your supervisor and/or workers compensation representative prior to reporting after missing time related to injury. Cooperate with nurse consultants and return-to-work efforts. Consult to locate a participating pharmacy. A First Script Pharmacy card is located in the Facilities Management Workers Comp Packet. The First Script network includes all major pharmacy chains, grocery stores and many single location pharmacies. You must take the First Script Pharmacy card to a participating pharmacy. Any questions, please contact Stephanie Burnette for Facilities Management employees at or OR Linda Coiner at or There is also a Workers Compensation Responsibility table included on the Human Resource website at located under the Benefits section. Forms are also located at this site.

3 Facilities Management Human Resources & Training Workers Compensation Information INSTRUCTIONS for the SUPERVISOR IMPORTANT NOTE: If employee does not require (or refuses) medical treatment, the injury must still be reported according to the following procedures. 1. Assist the injured employee with completing the UVa Agency 207 Accident Report for Workers Compensation Claim Form. 2. Present the injured employee with the UVa s Workers Compensation Attending Physician Panel Form. (NOTE: It is state law that the employee sign this form even if they do not seek medical treatment.) 3. Complete the Workers Compensation Supervisor s Accident Report Form. 4. Immediately report the injury to the Facilities Management Safety Office at (office) or cell numbers or Advise FM Safety Office of all updates and changes regarding the injured employee. 5. Return the originals of the following: Panel of Physicians Form UVa Agency 207 Accident Report for Workers Compensation Claim Form All Doctor s notes (Including Return to Work Release) Workers Compensation Supervisor s Accident Report Form To: Facilities Management Human Resources and Training Dept. PO Box Leake Building Charlottesville, VA Provide all subsequent information related to the employee s injury, absence, return to work, etc, to Human Resources and Training office immediately upon receipt.

4 University of Virginia Agency 207 Accident Report for Workers Compensation Claim This form to be completed by the injured employee and returned to Facilities Management Human Resources & Training. HR&T will submit data online to the Commonwealth of Virginia Workers Compensation Services provided by Managed Care Innovations (MCI) and will forward a copy to the University Human Resources Workers Compensation Coordinator, Box ; phone number Information Name: Assignment Number: Home Address: Home Phone: Work Phone: Cell Phone: Date of Birth: Sex: Marital Status: Department: Sub Agency Code: Occupation: Work hrs/day Date of Hire: Type (please check): Classified University Staff Hourly Faculty Information About Time/Place of Injury Date of Injury: Time: Exact Location: Date Accident Reported: Reported Accident to: Was Supervisor Notified (please check) Yes No Supervisor Name: Name of Witness(es) Information About the Nature and Cause of Accident Machine, tool, or object causing injury: Nature of injury (broken bone, strain, burn): Parts of body involved: Was safety equipment used: Yes No If so, what kind: Describe Fully How Injury Occurred

5 Was Medical Treatment Provided: Yes No Where: Was time lost from work: Yes No If yes, how long: Date Returned to Work: Signature: (Falsification of records is a serious misconduct, which may result in discharge) Date: Supervisor in Charge at the Time of Accident (Please complete) Was the employee doing something other than duties at the time of the accident: Yes No If yes, please explain: Did a non-university person contribute to the accident: Yes No If yes, please explain: Give accident causes and comment fully: Supervisors play an important role in providing safe work environments. What action is necessary to prevent reoccurrence of this type of accident: Has corrective action been taken: Yes No If corrective actions requires additional assistance (i.e., investigation or resources), please contact the Office of Environmental Health and Safety at Assistance will be promptly provided. Supervisor s Signature: Date: Work Phone Number: Space Provided for Additional Information as Needed:

6 Workers Compensation Attending Physician Panel for University Academic Division Faculty and Staff The University of Virginia is offering the following Attending Physician Panel in compliance with Section 65.2 of the Virginia Workers Compensation Act. The below panel is to be used by faculty and staff in the University s Academic Division (Agency 207). Injured Academic Division faculty and staff who have filed for Workers Compensation benefits must choose one physician for treatment of claimed, work-related injuries. Failure to choose one of the physicians listed below may bar compensation benefits, including the cost of medical care. s Primary Care Physicians are not authorized as attending physicians on UVa s Panel. Panel of Physicians Dr. David Rubendall Dr. Darlinda Grice UVA-WorkMed 1910 Arlington Blvd., Charlottesville Dr. William Dandridge Rose Hill Drive, Charlottesville Dr. Shelly Dawson MedExpress 1149 Seminole Trail, Charlottesville MedExpress Pantops Center, Charlottesville Panel physicians will make appropriate referrals to specialists. Emergency Facilities for Initial Emergency Visit Only UVA Health System Emergency Room Lee Street, Charlottesville Martha Jefferson Emergency Room Martha Jefferson Drive, Charlottesville I have been offered a choice of attending physicians from UVA s Workers Compensation Panel and have chosen the following physician: Name: Date: Signature: Please initial: I understand that I am responsible for any costs incurred in the event that Workers Compensation denies my claim.

7 PHARMACY: Commonwealth of Virginia participates in First Script, a pharmacy benefit program administered by Medco. Please call the First Script Help Desk, 24 hours a day, 7 days a week, at to verify employee eligibility. 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 approved claims. Online Claim Information Claims are processed through the Medco network Group # FSNCVTY BIN # PCN # Not Applicable Member ID# First Script will provide Member ID# upon verification of eligibility EMPLOYEE: First Script is valid only for medications prescribed for your work-related injury. You or your group health insurer, are financially responsible for any other prescriptions. First Script is available at nearly 56,000 pharmacies nationwide. To locate a nearby pharmacy, please call First Script Customer Service at Please present this form to your pharmacist along with your work related injury prescriptions. Pharmacy Benefit Program EMPLOYEE: Please complete the information below before giving this form to your pharmacist. Commonwealth of Virginia Employer Information Card UNIVERSITY OF VIRGINIA Agency Name Name Social Security Number Sub-Agency N/A Agency Code CV Questions? Call First Script Customer Service at

8 For Academic Division Supervisors and Staff Workers Compensation Responsibilities s of the University are responsible for conducting their work assignments in a safe and healthful manner in order not to expose themselves or colleagues to risks of bodily harm. When employees are injured while on the job from a risk not shared by the general public, or if they feel ill and suspect their illness is due to their work, it is their responsibility to report the injury and follow the guidelines below. Managed Care Innovations investigates each claim before making a determination. If the employee disagrees with the decision, they have the option of filing an appeal with the Commission. Supervisors can assist their staffs by familiarizing themselves with these guidelines and being prepared to help facilitate the workers compensation process, both by fulfilling their responsibilities (see numbers 2, 5a, and 6, below) and helping ensure that employees follow their guidelines. While these guidelines are available on the Web, not all University employees have ready access to the Internet, and some may be uncomfortable searching for and reading online information. Supervisors may wish to make printed copies of these Workers Compensation checklists available for their staffs. Step Task Who When 1. Report your injury or illness to your supervisor. Complete the Accident Report and submit to your supervisor. Immediately within two working days after 1a. If your supervisor is unavailable, contact their designated replacement or their supervisor. 2. Receive a list of physicians (called UVA s Workers Compensation Attending Physician Panel). This list is also available from Linda Coiner in the UHR Benefits Division at and on the UHR website at 3. Choose an attending physician from the list. Then indicate your choice on the list, sign the document, and return it to your supervisor. (If you choose to see a physician who is not on the University s Attending Physician Panel, you will personally be held responsible for any medical expenses and lost work time involved.) Supervisor. If supervisor is unavailable, employee should obtain this list the accident Immediately, if step 1 cannot be accomplished Immediately Immediately

9 Step Task Who When 4. Make an appointment with your chosen attending physician, and explain that you are a UVa employee who was injured at work or became ill because of your work. 4a. For emergency treatment, go to the UVa Hospital or Martha Jefferson Hospital emergency room for an initial visit and then follow up with one of the physicians on the list (see Step 2). As soon as medically necessary Immediately if an emergency 4b. Report this emergency to your supervisor immediately afterwards. Immediately-- within two working days after the accident 5 At your medical appointment, your attending physician will determine whether or not you should be excused from work and, if so, will give you a written work excuse. You must turn this work excuse in to your supervisor. 5a. If you turn in a work excuse to your supervisor, your supervisor must submit a copy to Linda Coiner in the UHR Benefits Division. 6. Your supervisor will report your injury or illness to Linda Coiner in the UHR Benefits Division by calling or sending an to 7. When Managed Care Innovations (MCI) contacts you for additional information, respond as soon as possible to their questions and phone calls. This information is needed to validate your claim, so it is to your advantage to respond immediately. 8. If you receive bills for medical care and/or prescriptions related to your injury or illness, contact the organization sending you each bill and inform that that injury or illness was work-related. Inform them that bills should be sent to: MCI P.O. Box 1140, Richmond, VA Supervisor Supervisor As soon as possible after your physician appointment As soon as possible Immediately 8a. s may contact MCI at with any questions. Optional As soon as possible, once you are contacted. MCI usually contacts employees within 24 hours. Immediately-if you receive bills

10 Step Task Who When 9. If you are enrolled in the Virginia Sickness and Disability Program (VSDP) and will be absent from work for more than seven calendar days, you must call to apply for disability benefits. As soon as you are seen by a physician and are out of work 9a. Contact your supervisor or the HR Service Center at if you are uncertain about whether or not you are enrolled in VSDP 10. If your attending physician prescribes a medication for your injury or illness, you must fill it through a participating First Script pharmacy. The First Script network includes all major pharmacy chains, grocery stores, discount stores, and many single-location pharmacies. To locate a pharmacy and to print a card, visit the Commonwealth of Virginia Workers Compensation Services website at When you submit your first prescription at the pharmacy, present your pharmacy card. The pharmacy will check for eligibility. The pharmacy will fill your first prescription and will verify that the claim has been accepted before allowing any refills. 11. The Virginia Workers Compensation Act (Title 65.2) and the Virginia Personnel Act provide compensation to you or your dependents in the event of injury, illness, or death arising out of and in the course of employment. The injury must arise from a risk not shared by the general public. To receive these benefits, you must meet the criteria described in numbers 1, 2, 3, and 4 above. NOTE: If you refuse to accept medical care when provided by a panel physician, you will be disqualified from further compensation until you choose to accept this care. Failure to follow the prescribed treatment of your physician may result in the cancellation of all compensation. 11a. If your injury or illness is accepted as compensable under the Workers Compensation Act, the University will pay salary compensation and medical care costs. If your injury or illness is not a result of your work, you will be held responsible for both time lost from work and for your medical care costs. Managed Care Innovations investigates each claim before making a determination. If the employee disagrees with the decision, they have the option of filing an appeal with the Commission. Present the drug card to your pharmacy at the time you receive a prescription medication. Provide information to your health care provider about other insurance you may have should your injury or illness not be

11 considered work related. If you have questions regarding UVA Workers Compensation policies and procedures or the Workers Compensation Act, please contact: Linda Coiner University Human Resources Benefits Division 914 Emmet Street Phone: , 8AM 5PM, Monday Friday Fax:

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