RE: Workers Compensation Claims Kit. Dear Policyholder:

Transcription

1 RE: Workers Compensation Claims Kit Dear Policyholder: Welcome to Tower Group Companies Workers Compensation Insurance Program. Although we hope that your company never experiences an injury to an employee, we want you to have all the information you might need in the event one occurs. Enclosed is our Workers Compensation Injury Reporting Kit that contains the South Carolina state-mandated Forms and step-by-step process to follow in case an employee sustains an injury. When a claim occurs, see the attached instructions for reporting a claim to our Claims Intake Unit. The contact information for the Claims Intake Unit is listed on the How to File an Injury form included in this packet. The Tower Group claim office which will be handling your claim is located in Maitland, Florida. Once reported, a claims representative will contact you to obtain additional information about the injured employee and to answer any questions that you might have regarding the South Carolina workers compensation process. The following state forms are included in your claims kit packet: 1. South Carolina First Report of Injury or Illness- Form 12A- (rev 04/2006)- This form must be completed by the employer when an employee reports and injury or accident. Please complete the form with as much available information as possible. 2. South Carolina Temporary Compensation Report Form 15- (rev 10/2004)- The insurance company must complete and file this form with the South Carolina Workers Compensation Commission within ten (10) days after compensation begins or is terminated. The insurance company must serve Form 15 on the claimant when compensation begins. 3. South Carolina Supplemental Report of Varying Temporary Partial Payments Form 15S- (rev 03/1997)- Supplemental payments shall be reported on a Form 15S, which is to be filed with the document stopping that period of temporary partial compensation. 4. South Carolina Receipt of Compensation- Form 17 (rev 03/1997)- This form must be filed with the South Carolina Workers Compensation Commission no later than thirty-one (31) days from the date the claimant returned to work in order to terminate temporary compensation after the first 150 days after employer s notice of injury. Within the 150- day period, obtain form to document that claimant agrees he or she is able to return to work. 5. South Carolina Form 20- Statement of Earning of Injured Employee- This form is required in any admitted case to initiate TTD. If the case is denied, this must be done within thirty (30) days from the hearing request. This form is mandatory on all claims involving lost time or permanent benefits. 6. Medical Authorization- Please have the injured employee fill out and sign this form and send to Tower Group Companies at the time of an injury. We thank you for your business and look forward to being of service to you. Very truly yours, Tower Group Companies CL TGC (08/10)

2 HOW TO FILE A WORK INJURY OR ILLNESS CLAIM Workers compensation claims can be reported in several different ways, you can: Complete and submit the South Carolina First Report of Injury or Illness- Form 12A- (rev 04/2006)- and submit the form via one of the following: the completed form to wcreportaloss@twrgrp.com. This is the preferred method of reporting an injury. Fax to Tower Group Companies at Call the Tower Group Companies Claims office at By contacting your broker directly and providing the appropriate first report information. For injuries occurring after normal business hours, please call The after hours telephone number for reporting claims provides the opportunity to report a claim 24 hours a day 7 days a week. Loss details will be gathered to determine if an emergency exists and if an immediate field contact is indicated. IN02 08/08

3 S.C. WORKERS COMPENSATION COMMISSION FIRST REPORT OF INJURY OR ILLNESS EMPLOYER (NAME & ADDRESS INCL ZIP) CARRIER/ADMINISTRATOR CLAIM NUMBER OSHA LOG NUMBER REPORT PURPOSE CODE JURISDICTION JURISDICTION CLAIM NUMBER INSURED REPORT NUMBER EMPLOYER S LOCATION ADDRESS (IF DIFFERENT) LOCATION # INDUSTRY CODE EMPLOYER FEIN PHONE # CARRIER/CLAIMS ADMINISTRATOR CARRIER (NAME, ADDRESS, & PHONE #) POLICY PERIOD CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO) TO CHECK IF APPROPRIATE SELF INSURANCE CARRIER FEIN POLICY/SELF-INSURED NUMBER ADMINISTRATOR FEIN AGENT NAME & CODE NUMBER EMPLOYEE/WAGE NAME (LAST, FIRST, MIDDLE) DATE OF BIRTH SOCIAL SECURITY NUMBER DATE HIRED STATE OF HIRE ADDRESS (INCL ZIP) SEX MARITAL STATUS OCCUPATION/JOB TITLE Male Female Unknown Unmarried/Single/Divorced Married Separated EMPLOYMENT STATUS Unknown NCCI CLASS CODE PHONE # OF DEPENDENTS RATE PER: DAY WEEK MONTH OTHER: DAYS WORKED/WEEK FULL PAY FOR DAY OF INJURY? YES NO DID SALARY CONTINUE? YES NO OCCURRENCE/TREATMENT TIME EMPLOYEE BEGAN WORK AM DATE OF INJURY/ILLNESS TIME OF OCCURRENCE AM LAST WORK DATE DATE EMPLOYER NOTIFIED DATE DISABILITY BEGAN PM ( ) CANNOT BE DETERMINED PM CONTACT NAME/PHONE NUMBER TYPE OF INJURY/ILLNESS PART OF BODY AFFECTED DID INJURY/ILLNESS/EXPOSURE OCCUR ON EMPLOYER S PREMISES? TYPE OF INJURY/ILLNESS CODE PART OF BODY AFFECTED CODE YES NO DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL CAUSE OF INJURY CODE DATE RETURN(ED) TO WORK IF FATAL, GIVE DATE OF DEATH WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? YES NO WERE THEY USED? YES NO PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS) HOSPITAL OR OFF SITE TREATMENT (NAME & ADDRESS) INITIAL TREATMENT 0 NO MEDICAL TREATMENT 1 MINOR: BY EMPLOYER 2 MINOR CLINIC/HOSP 3 EMERGENCY CARE 4 HOSPITALIZED > 24 HOURS FUTURE MAJOR MEDICAL/ LOST TIME 5 ANTICIPATED OTHER WITNESSES (NAME & PHONE #) DATE ADMINISTRATOR NOTIFIED DATE PREPARED PREPARER S NAME & TITLE PHONE NUMBER WCC FORM 12A REV. DATE 04/06 SEE INSTRUCTIONS FOR IMPORTANT INFORMATION REPRINTED WITH PERMISSION OF IAIABC

4 South Carolina Workers Compensation Commission 1612 Marion St. P.O. BOX 1715 Columbia, SC EMPLOYER S INSTRUCTIONS DO NOT ENTER DATA IN SHADED FIELDS DATES: Enter all dates in MM/DD/YYYY format. INDUSTRY CODE: This is the code which represents the nature of the employer s business, which is contained in the Standard Industrial Classification Manual or the North American Industry Classification System, published by the Federal Office of Management and Budget. CARRIER: The licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of the employer of the claimant. CLAIMS ADMINISTRATOR: Enter the name of the carrier, third party administrator, state fund, or self-insured responsible for administering the claim. AGENT NAME & CODE NUMBER: Enter the name of your insurance agent and his/her code number if known. This information can be found on your insurance policy. OCCUPATION/JOB TITLE: This is the primary occupation of the claimant at the time of the accident or exposure. EMPLOYMENT STATUS: Indicate the employee s work status. The valid choices are: Full-Time On Strike Unknown Volunteer Part-Time Disabled Apprenticeship Full-Time Seasonal Not Employed Retired Apprenticeship Part-Time Piece Worker DATE DISABILITY BEGAN: The first day on which the claimant originally lost time from work due to the occupation injury or disease or as otherwise designated by statute. CONTACT NAME/PHONE NUMBER: Enter the name of the individual at the employer s premises to be contacted for additional information. TYPE OF INJURY/ILLNESS: Briefly describe the nature of the injury or illness, (e.g. Lacerations to the forearm). PART OF BODY AFFECTED: Indicate the part of body affected by the injury/illness, (e.g. Right forearm, lower back). DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED: (e.g. Maintenance Department or Client s office at 452 Monroe St., Washington, DC 26210) If the accident or illness exposure did not occur on the employer s premises, enter address or location. Be specific. WCC FORM 12A REV. DATE 04/06

5 South Carolina Workers Compensation Commission 1612 Marion St. P.O. BOX 1715 Columbia, SC EMPLOYER S INSTRUCTIONS cont d ALL EQUIPMENT, MATERIAL OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED: (e.g. Acetylene cutting torch, metal plate) List all of the equipment, materials, and/or chemicals the employee was using, applying, handling or operating when the injury or illness occurred. Be specific, for example: decorator s scaffolding, electric sander, paintbrush, and paint. Enter NA for not applicable if no equipment, materials, or chemicals were being used. NOTE: The items listed do not have to be directly involved in the employee s injury or illness. SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED: (e.g. Cutting metal plate for flooring) Describe the specific activity the employee was engaged in when the accident or illness exposure occurred, such as sanding ceiling woodwork in preparation for painting. WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED: Describe the work process the employee was engaged in when the accident or illness exposure occurred, such as building maintenance. Enter NA for not applicable if employee was not engaged in a work process (e.g. walking along a hallway). HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL: (Worker stepped back to inspect work and slipped on some scrap metal. As worker fell, worker brushed against the hot metal.) Describe how the injury or illness/abnormal health condition occurred. Include the sequence of events and name any objects or substance that directly injured the employee or made the employee ill. For example: Worker stepped to the edge of the scaffolding to inspect work, lost balance and fell six feet to the floor. The worker s right wrist was broken in the fall. DATE RETURN(ED) TO WORK: Enter the date following to most recent disability period on which the employee returned to work. WCC FORM 12A REV. DATE 04/06

6 South Carolina Workers Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC (803) Claimant's Name: SSN: - - Employer's Name: WCC File #: Carrier File #: Carrier Code #: Employer FEIN #: Home Phone: ( ) - Work Phone: ( ) - Insurance Carrier: Preparer s Name: Law Firm: Preparer s Phone #: ( ) - Date of injury: (m/d/yyyy) Date of Notice to Employer of Injury: (m/d/yyyy) I. Payment of Temporary Compensation Check one: Initial period Additional period Corrected compensation rate (choose A, B, or C) A. Temporary Total at the compensation rate of $ per week. For this period of disability, disability began on (m/d /yyyy) and the date of first payment was (m/d/yyyy). B. Temporary Partial at the compensation rate of $ per week. Note: When the Temporary Partial compensation rate will vary, report the first payment here. Supplement this report throughout the period of Temporary Partial compensation by filing a Form 15S with the Form 18, which shall be filed six months after the date of injury and each six months thereafter until the file is closed. For this period of disability, disability began on (m/d/yyyy), and the date of first payment was (m/d/yyyy). Calculation of Temporary Partial Rate: Average weekly wage before injury $ Current weekly wage $ = Difference in wages before injury and now $ 0.00 x.6667 $ 0.00 Temporary Partial Compensation Rate $ 0.00 C. Salary in lieu of Temporary Total Partial (choose one) compensation in the amount of $ per week. For this period of disability, disability began on (m/d/yyyy) and the date of first payment of salary in lieu of temporary compensation was (m/d/yyyy). THIS SECTION MAY BE USED ONLY WITHIN 150 DAYS AFTER NOTICE TO EMPLOYER OF INJURY. ATTACH DOCUMENTATION AS TO THE REASON OF THE TERMINATION. II. Termination of Temporary Compensation Temporary compensation payments were stopped on (m/d/yyyy) for the following reason: Claimant has returned to work at least 15 days and no temporary partial compensation is due. Claimant agrees he/she is able to return to work and has signed a Form 17. Based on a good faith investigation, the claim is denied. Reason for denial: Claimant has been released to return to work without restrictions and employment has been offered. Claimant has been released to work at limited duty and employer has provided limited duty work consistent with the terms upon which the Employee has been released. Claimant has refused medical treatment, examination, or evaluation. Note: Benefits must be resumed if claimant accepts the treatment, examination, or evaluation. Additional report must be filed if compensation is resumed. I certify that this form has been served on the claimant per R Signature of Claims Administrator Date (m/d/yyyy) III. Notice to Injured Worker or Legal Representative when Temporary Compensation Has Been Stopped: The employer s representative may stop temporary compensation within 150 days of the date of notice of injury for the above reasons. However, if you believe that the temporary compensation should not have been stopped, you may request a hearing by signing below and returning this form to SCWCC Judicial Department at the address at the top of this form. A hearing will be held within 60 days of receipt of your request to determine if temporary compensation has been properly terminated. MY SIGNATURE BELOW INDICATES THAT I DO NOT AGREE WITH THE TERMINATION OF TEMPORARY COMPENSATION. I REQUEST A HEARING TO DETERMINE WHETHER I AM ENTITLED TO FURTHER TEMPORARY COMPENSATION PAYMENTS. Check one: Form 15(II) Has Has not been received. Signature of Claimant or Legal Representative Date (m/d/yyyy) Employer s representative must complete and file Form 15 with Claims Department within ten days after compensation begins or is terminated. Employer s representative must serve the Form 15 on the claimant when compensation begins per R Employer s representative must prepare and serve Form 20 within thirty days of beginning compensation per R Employer s representative must serve per R two copies of the Form 15 on claimant immediately on termination of compensation with documentation attached as to the reason for the termination. Injured worker may contest termination of compensation by completing section III of the Form 15 and filing it with Judicial Department. WCC Form # 15 TEMPORARY COMPENSATION REPORT Rev. 10/04 15

7 South Carolina Workers Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC (803) WCC File #: Carrier File #: Carrier Code #: Employer FEIN #: Claimant's Name: SSN: - - Home Phone: ( ) - Work Phone: ( ) - Employer's Name: Insurance Carrier: Preparer s Name: Law Firm: Preparer s Phone #: ( ) - Supplemental Report of Varying Temporary Partial Payments Date of injury: (m/d/yyyy) In an ongoing period of temporary partial, when the compensation rate varies from week to week, the employer s representative shall report the first payment on a Form 15 according to R Supplemental payments shall be reported on a Form 15S, to be filed with the document stopping that period of temporary partial compensation or with the Form 18, which shall be filed six months after the date of injury and each six months thereafter until the file is closed. R WCC Form # 15S 15S Supplemental Report of Varying Rev. 3/97 Temporary Partial Payments

8 South Carolina Workers Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC (803) WCC File #: Carrier File #: Carrier Code #: Employer FEIN #: Claimant's Name: SSN: - - Home Phone: ( ) - Work Phone: ( ) - Employer's Name: Insurance Carrier: Preparer s Name: Law Firm: Preparer s Phone #: ( ) - Date of injury: (m/d/yyy) 1. Temporary Compensation Paid: Number of Weeks From To Amount $ 2. The claimant returned to work on With restrictions but at a salary not less than before the injury. (m/d/yyyy) Without restrictions. $ $ $ $ 3. The claimant agrees he or she was able to return to work on. (m/d/yyyy) I agree that I was disabled for the period(s) indicated and I was paid compensation as shown above. I UNDERSTAND THAT MY WEEKLY TEMPORARY COMPENSATION CHECKS WILL STOP; HOWEVER, I GIVE UP NO RIGHTS TO COMPENSATION FOR FUTURE DISABILITY, FOR PERMANENT DISABILITY, DISFIGUREMENT OR MEDICAL CARE. The effect of this form has been fully explained to me, and I have received a copy of it. I understand that I should not sign this form until 15 days after I have returned to work or agree I was able to return to work. Claimant s Signature Employer s Representative Signature (Check one) Witness Claimant s Attorney Date Agreement Signed File this form with the Claims Department no later than 31 days from the date the claimant returned to work to terminate temporary compensation after the first 150 days after employer s notice of the injury according to R Within the 150 period, obtain Form 17 to document that claimant agrees he or she is able to return to work. WCC Form # 17 Rev. Date 3/97 17 RECEIPT OF COMPENSATION

9 South Carolina Workers Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC (803) WCC File #: Carrier File #: Carrier Code #: Employer FEIN #: Claimant's Name: SSN: - - Home Phone: ( ) - Work Phone: ( ) - Preparer's Name: Employer's Name: Insurance Carrier: Preparer s Phone #: ( ) - A. Total Wages Paid 1. Check Applicable Method: Report of earnings of injured employee based on four completed quarters. Report of earnings of injured employee who did not complete four quarters based on actual time worked. Date of Injury: Report of earnings of similar employee. Injured employee did not work sufficient time before alleged injury. Hire date: Report of earnings of injured employee based on alternative method because Form 20 results in a compensation rate that is not fair and just (attach documentation to show how average weekly wage and compensation rate were calculated). month day year 2. List total wages paid as reported to the Employment Security Commission on the Employer Quarterly Contribution and Age Reports during the four quarters immediately preceding the quarter in which the injury occurred. Do not include the quarter during which the injury occurred. Quarter Ending Date Total Wages Paid 1st $ 2nd $ 3rd $ 4th $ Total Paid 2. $ List total value of other allowances of any character made in lieu of wages during four quarters above. 3. $ 4. Add lines 2 and 3. TOTAL WAGES PAID: 4. $ List total number of weeks paid to employee during the four quarters immediately preceding the quarter in which the injury occurred. 5. B. Average Weekly Wage 6. To calculate average weekly wage, divide total wages (line 4) by total weeks paid (line 5). AVERAGE WEEKLY WAGE: 6. $ C. Compensation Rate 7. The general rule for calculating the compensation rate is to multiply average weekly wage (line 6) by Estimate compensation rate by multiplying average weekly wage (line 6) by See part 8 below to 7. $0.00 determine the actual compensation rate. 8. The compensation rate is as follows (choose one): When average weekly wage (line 6) is less than $75.00, the compensation rate is the average weekly wage. Enter average weekly wage on line 8. When the estimated compensation rate (line 7) is less than $75.00 and average weekly wage (line 6) is more than $75.00, the compensation rate is $ Enter $75.00 on line 8. When the estimated compensation rate (line 7) is more than the maximum compensation rate for the year in which the injury occurred, enter the maximum compensation rate for the year in which the injury occurred on line 8. Employee is within the exceptions listed in S.C. Code Ann. Section List applicable exception here and enter appropriate compensation rate on line 8. The calculated compensation rate (line 7) applies. Enter amount from line 7 on line 8. WEEKLY COMPENSATION RATE: 8. $ Employer s representative shall prepare a Form 20 and serve per R a copy on the claimant within thirty days of beginning temporary compensation. See R when no temporary compensation is paid. NOTE: Average weekly wage represents average gross pay before taxes and other deductions. WHEN THE CLAIMANT DOES NOT AGREE WITH THE COMPENSATION RATE ON LINE 8, HE OR SHE SHOULD CONTACT THE EMPLOYER S REPRESENTATIVE TO TRY TO REACH AN AGREEMENT AS TO THE COMPENSATION RATE. IF NO AGREEMENT CAN BE REACHED, THE CLAIMANT SHOULD CONTACT THE CLAIMS DEPARTMENT AT (803) WCC Form # 20 Rev. Date 3/97 20 STATEMENT OF EARNINGS OF INJURED EMPLOYEE

10 WORKERS COMPENSATION INJURY MEDICAL AUTHORIZATION Authorization for Medical Records And Communication Release By this form or copy thereof, I, hereby authorize any licensed physician, chiropractor, medical practitioner, hospital, clinic or other related medical or medically related facility, insurance company or other organization, institution, or person, that has any records or knowledge of my mental, physical health, history, condition or well being, to supply such information to my employer, it s insurer, claims administrator, rehabilitation or medical management consultant or attorneys. I specifically authorize any treating physician or medical care provider to communicate orally or in writing with my employer, it s insurer, claims administrator, rehabilitation or medical management consultant or attorneys as to my care and treatment and as to any other issues including but not limited to diagnosis, prognosis, causal connection of care and treatment to my work injury or duties and ability to work. In conjunction with this, I authorize any treating physician or medical provider to review any additional medical records provided to them. I understand that by signing this authorization for medical records and communication release that my applicable medical provider will be releasing information subject to the HIPPA restrictions. I specifically waive any rights or protections that I may have under the HIPPA regulation and request that the medical providers release the requested information. A photo copy of this authorization shall be valid as the original. This release shall remain valid for the length of my claim. Name (Please Print) Address (Street, City/Town, Zip Code) Signature Date Signed TWR05 08/08

11 WORKERS COMPENSATION MANAGED CARE PROGRAMS Tower Group Companies strives to deliver the highest quality and value of workers compensation products and services to our customers. We are committed to providing excellent customer service and products which will meet our customers needs in managing their workers compensation claims. Tower Group Companies participates in several Managed Care Initiatives through a Partnership with Coventry Workers Comp Services. These initiatives help to reduce workers compensation medical related expenses with a focus of timely return to work for your injured worker. A summary of each program is outlined below. Medical Bill Review Services The Medical Bill Review Services Program provides an opportunity to reduce your medical costs. The program helps to obtain the maximum savings available on every bill by processing each bill through an extensive database of state fee schedules, usual and customary charge reviews, diagnostic related group reviews, and national Preferred Provider Organizations (PPO) Network discounts. Additional savings are obtained by hospital bill auditing and out of network negotiation programs. Network Providers - Coventry Workers Comp Services provides one of the largest national workers compensation discount networks in the industry. It is comprised of the First Health, FOCUS, MetraComp, and Aetna networks; as well as other top regional PPO s. The combination of these network providers offers coverage in every jurisdiction in the country resulting in superior network savings and increased medical provider availability. These networks are comprised of medical providers specializing in occupational medicine and services focusing on quality of care and expedited return to work for the injured employee. Coventry credentials each provider within the network to provide quality medical service and who is dedicated to returning the injured employee to work. In some states, such as California and Texas state regulations allow specialty networks which provide you as an employer more control over your workers compensation medical and disability costs. The physicians within these networks are educated in evidence based treatment protocols assisting the injured employee in reaching early Maximum Medical Improvement (MMI) in accordance with medical industry guidelines. Other benefits include reduction in over utilization of medical services and excessive treatment costs with the focus in early return to work, thereby reducing your workers compensation indemnity payments. One of the first steps in providing quality medical care to your injured employee is to understand how to access network providers, and generate workplace provider panel cards or provider listings. There are two convenient ways to locate a network provider or develop provider network listings: 1. Telephonically: Simply call Coventry at x Provide the Coventry representative your employer information, the specific provider specialty you need and your geographic area (city, state and zip code). The Coventry representative will provide verbally provide you with a list of providers meeting your requirements or an electronic provider directory can be forward to you via Internet Access: For the standard national workers compensation network go to and select the Coventry Integrated Network to search for providers in your geographic network. You will be able to generate provider directories as well as determine whether a specialty physician is a member of the Network.

12 If you participate in a Specialty Network, such as a MPN or HCN, select the applicable network from the drop-down box. For California, chose the First Health Select CA MPN; Texas participants in the Coventry HCN. For large panel card production or if you require additional information regarding web access please contact Tower Group Medical Management division at Medical Case Management - Coventry Workers Comp Services provides you with a variety of programs to help manage the care of your injured employees, including medical case management, catastrophic case management, vocational case management, utilization reviews (URAC certified), return-to-work programs, and independent medical examinations. All of these programs are dedicated to advocating appropriate, highquality medical treatment, facilitating prompt return to work and effectively managing your claim costs. Experienced medical professionals work with treating physicians and your claims adjuster as advocate for the injured employee s medical care. These professionals ensure that your employee receives the most appropriate and timely care. Facilitating effective communication between medical providers and claims adjusters also provides a quicker resolution of your claims. Tower s dedicated team of adjusters will facilitate the integration of these products and services to assist in reducing injured employee s lost time and medical costs. Your Tower Group designated adjuster will be responsible for managing all aspects of the injured employee s claim and facilitating open lines of communication between all parties to resolve any outstanding issues or concerns. Please feel free to contact your claims adjuster, or Tower Group Managed Care Services, if you have any questions regarding these programs.

13 First Fill Temporary Pharmacy Card Making it easy to get your workers compensation prescriptions filled. Employer: Immediately upon receiving notice of injury, fill in the information below and give it to your employee. Injured Employee: 1. If you need a prescription filled for a work-related injury or illness, go to a Tmesys network pharmacy. 2. Give this page to the pharmacist. 3. The pharmacist will fill your prescription at no cost. Questions? Call Necesitas ayuda en español? Llame al Prescription Card CARRIER / TPA INJURED WORKER NAME SOCIAL SECURITY NUMBER EMPLOYER DATE OF INJURY Attention Pharmacists: Call to establish First Fill benefit eligibility and obtain the ID# for online adjudication of approved benefits for the injured worker. Tmesys is the designated PBM for this patient. Tmesys Pharmacy Help Desk Notice to Cardholder: This card should be presented to your pharmacy to receive medication for your work-related injury. It is only valid within 30 days of your date of injury. For information regarding the program or to find nearby pharmacies call NDC Envoy RxBin or RxPCN CAL or Envoy Acct. # Pharmacist: 1. Call the Tmesys Pharmacy Help Desk at Provide the information from the card. 3. The Help Desk will provide an ID number for adjudication. (To create a card for your wallet, cut along outer line and fold in half.) Finding a Network Pharmacy Use one of these easy methods to find a network pharmacy: Visit your local Walgreens or Rite Aid Pharmacy Call us: Use our pharmacy locator online: PMSI, Inc. All rights reserved. C

14 First Fill Temporary Pharmacy Card En Primer Relleno Tarjeta Temporal de Farmacia Hacerlo fácil de llenar sus recetas de la compensación del trabajador. Employer: Immediately upon receiving notice of injury, fill in the information below and give it to your employee. Empleado Lesionado: 1. Si usted necesita una receta para un accidente de trabajo o enfermedad ocupacional, ir a una farmacia de la red Tmesys. 2. Dar esta página al farmacéutico. 3. El farmacéutico surtir su receta sin costo alguno. Preguntas? Llame al Need help in English? Call Prescription Card PORTADORA NOMBRE DEL TRABAJADOR LESIONADO NUMERO DE SEGURO SOCIAL EMPLEADOR FECHA DE LA LESIÓN Attention Pharmacists: Call to establish First Fill benefit eligibility and obtain the ID# for online adjudication of approved benefits for the injured worker. Tmesys is the designated PBM for this patient. Tmesys Pharmacy Help Desk Aviso a los titular de la tarjeta: Esta tarjeta debe ser presentada a su farmacia para recibir medicamento para tratar su lesión relacionada con el trabajo.sólo es válido dentro de los 30 días de su fecha de la lesión. Para obtener información acerca del programa o para encontrar farmacias cercanas llame NDC Envoy RxBin or RxPCN CAL or Envoy Acct. # (Para crear una tarjeta para su billetera, corte a lo largo de la linea exterior y doblar por la mitad.) Pharmacist: 1. Call the Tmesys Pharmacy Help Desk at Provide the information listed above. 3. The Help Desk will provide an ID number for adjudication. Encontrar una farmacia de la red Utilice uno de estos métodos fáciles para encontrar una farmacia de la red: Visite a su local de Walgreens y Rite Aid Pharmacy. Nos llame al: Utilice nuestro localizador de farmacias en linea: PMSI, Inc. Todos los derechos reservados. C

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