Cherry Creek School District Employees. Karyn Fast, Risk Manager Christine Baxter, Risk Management Specialist Sherry Mars, Risk Management Specialist

Transcription

1 Office of Risk Management 4850 South Yosemite Street Greenwood Village, Colorado FAX: TO: FROM: Cherry Creek School District Employees Karyn Fast, Risk Manager Christine Baxter, Risk Management Specialist Sherry Mars, Risk Management Specialist DATE: August 1, 2016 SUBJECT: Workers Compensation (1) Administration (2) Procedures Workers Compensation claims are administered by the Risk Management Department in the Fiscal Services Division located in the Auxiliary Services Center. All work related injury information including first reports of injury, designated physicians work status reports, notification of lost time due to a work related injury, return to work releases, any questions, can be directed to Christine Baxter ( ), Sherry Mars ( ) or riskmanagement@cherrycreekschools.org. The Colorado Workers Compensation Statute is very specific on the timelines for reporting of work related injuries by the employee, as well as by the employer. Fines and penalties can be assessed for late reporting against both the employee and/or the employer. The law requires the injured employee to report the work-related injury in writing within 4 working days of the accident (see attached Employer s First Report of Injury). We must have the completed first report of injury in our third party administrator s office within 8 days of the injury and they must file it with the State Division of Workers Compensation within 20 days of the injury to admit liability or deny the claim. We have attached procedures to establish the required process for seeking medical treatment, reporting claims, statutory timelines and forms to be used for work related injuries. We have also included a Workers Compensation Program Employee Information document to assist you in the completion of the First Report of Injury form. This document should give you a general overview of how the Workers Compensation system operates. If you have questions, or if we can further assist you, please feel free to give one of us a call. cc: Guy G. Bellville, Chief Financial Officer

2 Cherry Creek School District Workers Compensation Program Employee Information Introduction The Colorado Workers Compensation Act (Title 8) establishes that employers, such as Cherry Creek School District, must provide medical care and a scheduled amount of Wage Loss Benefit to employees who sustain an injury or illness arising out of their employment. This obligation can be met either by purchasing insurance or by self-insuring the risk. The District has elected to self-insure this obligation through the Joint School Districts Workers Compensation Self Insurance Pool. The following are instructions for making a claim under the District s Workers Compensation Program and a brief outline of benefits. This information is not meant to be a detailed explanation of the Workers Compensation Statute. If more specific information is desired please contact the Colorado Division Of Workers Compensation or the Office of Risk Management. Medical Care Medical expenses, including hospital charges, bills from designated physicians, prescriptions, etc. for work related injuries and illness are covered under the District s Workers Compensation Program. Except in cases of extreme emergency, such as life or limb threatening, medical treatment is to be obtained only from one of the medical facilities designated by the District. You may select from the four corporate medical providers listed on the provider list where you want to receive treatment for your work related injury. Follow-up care, after receiving emergency medical treatment, must be provided by one of the designated providers listed on the provider list the next day or as soon as possible. The District has designated Concentra, Health One Occupational Medicine and Rehabilitation, Rocky Mountain Medical Group and US Health Works Medical Group as the facilities for treatment of work related injuries/illnesses. An Authorization for Medical Treatment form is included that will need to be signed by the building nurse or your supervisor. You will need to bring the form with you to present at the facility you have chosen from the Provider List. In case of extreme emergency (life or limb threatening), or if you are outside the Denver Metropolitan Area on District related business, go immediately to the nearest emergency medical facility for treatment. Either you or your representative must contact the District s Risk Management Office, Christine Baxter ( ) or Sherry Mars ( ), by the following work day to report the injury and select a provider. If any employee wishes to receive medical care for a work related injury/disease from his/her personal physician or a provider other than those that have been authorized by our insurance company, it will be at the employees own expense. Prescription Drug Program Cherry Creek Schools has contracted with mymatrixx to have prescriptions for your work related injury filled at no expense to you. A temporary card will be provided to you at your initial doctor s visit. Authorization cards will be mailed directly to you after your claim has been filed. Simply take the authorization card, along with your prescription, to the nearest participating pharmacy. mymatrixx will bill our Workers Compensation third party administrator directly.

3 Wage Loss Benefits If you lose more than three days of work because of a work related injury or disease, you are entitled to compensation equal to two thirds (66%) of your average weekly wage subject to a maximum figure, which is established and adjusted each year by statute. The District will allow you to use up to 3 days of your accumulated sick leave days for absence due to a work-related injury, but only if the work comp doctor takes you off duty and/or restrictions do not allow for return to work. Thereafter, you will receive the Statutory Workers Compensation Benefits. In the event you are physically unable to return to the type of work you were doing with the district or in the event you sustain some permanent physical impairment, permanent disability benefits as established by the Colorado Workers Compensation Act may be payable. Mileage Reimbursement Benefits Workers Compensation will reimburse you at the statutory rate for trips to and from the doctor and/or physical therapy. Mileage reimbursement request forms are available in each school nurse s office or in the main office of each building. Reimbursement will be made by our Workers Compensation third party administrator, after the required forms have been completed and furnished to their office. Claim Denials or Notice of Contest Because an employer is required to file an admission or denial of liability with the Colorado Division of Workers Compensation within a limited amount of time where more than 3 days of lost time occurs, you may receive a copy of a form from the adjuster entitled Notice of Contest. This form in most cases means that the adjuster has been unable to review the claim within the time limitations to be able to accept the claim as compensable. In most cases, you will receive an additional form admitting coverage or a letter denying the claim. If the claim is denied, you can either obtain the benefits available to you through the benefits program for medical expenses and lost time or you can request a hearing at the Division of Workers Compensation. Should a question arise concerning a claim you have filed, you can direct your questions to the Office of Risk Management or to the adjuster from CCMSI (Cannon Cochran Management Services Inc.) who is handling your claim.

4 Cherry Creek School District s Designated Provider s List Concentra Concentra E. Iliff Ave Dr. Diane Adams, DO Aurora, CO Phone: Hours: 8am-5pm, M-F Concentra E. Arapahoe Rd. Suite 100 Dr. Carrie Burns, MD Centennial, CO Phone: Hours: 8am-6pm, M-F Health One Occupational Medicine and Rehabilitation Health One Occupational Medicine 1444 S Potomac St, #200 Dr. Matthew Lugliani, M.D., MPH Aurora, CO Phone: Hours: 7am - 5pm, M-F Health One Occupational Medicine E Arapahoe Rd, #160 Dr. Broghammer M.D. Dr. Hiep Ritzer, M.D. Phone: Hours: 7am - 5pm, M-F Rocky Mountain Medical Group Rocky Mountain Medical Group E. Mississippi Ave, Suite 120 Dr. Annu Ramaswamy, M.D. Aurora, CO Dr. Brian Beatty, D.O. Phone: Hours: 8am - 5pm, M-F U.S. Health Works Medical Group U.S. Health Works Medical Group 8200 E. Belleview, Suite 428C Dr. Nelson M.D Greenwood Village, CO Dr.Rossi, M.D. Phone: Hours: 8am 5pm, M-F After Hours and Emergency Care Centennial Medical Plaza After Hours and Emergency Room Only -OR- Nearest Emergency Facility E. Arapahoe Road Phone:

5 Your Responsibilities As an employee of the District you have certain responsibilities in your Workers Compensation claim. responsibilities are as follows: Your 1. Any work related injury or disease must be reported to your supervisor or building administrator within 48 hours of the occurrence or onset of the disease. This includes those accidents that do not require medical treatment. 2. Written notice of an injury resulting from an accident must be given by you to the Risk Management Office within 4 working days after the accident. Failure by you to give this written report may result in penalties being imposed against you. 3. If requested by your supervisor, you will assist in the completion of the form entitled Employer s First Report of Injury. This form may be completed by your supervisor and/or their designee. The completed form must be sent to the District s Risk Management Office within 4 calendar days of the injury or onset of the disease. 4. If medical treatment is required, you should first be examined by the nearest District nurse. If further medical treatment is necessary, obtain an Authorization for Medical Treatment from the school nurse or supervisor. In accordance with Colorado Revised Statute (5) (a), you can select from the list of corporate medical providers designated by the District (Concentra, Health One Occupational Medicine and Rehabilitation, Rocky Mountain Medical Group, or U.S. Health Works) for treatment of your work related injury. Emergency life and limb threatening treatment should be obtained at the nearest medical facility and all follow-up care needs to be provided at one of the above selected designated providers the following day. 5. The physician will provide you with a copy of the treatment form, which will contain the physician s diagnosis, a release to return to work, any work restrictions, follow-up appointment dates, or time off work requirements. You must return a copy of the doctor s report to your supervisor after each doctor s visit. Subsequent follow up appointments or therapy visits should be recorded as sick/general leave absence. It is your duty and responsibility to keep your supervisor advised on your medical updates and return to work status. 6. Your claim will be adjusted by a person retained by the District s insurance pool. It will be necessary for you to cooperate fully with the adjuster, supply any information required including a signed release and attend any medical or vocational evaluations that are arranged for you. 7. All bills you receive should be forwarded to the Risk Management Office. We will forward the bills to our adjuster for review. If the claim is accepted, bills will be paid based on the Colorado Workers Compensation Fee Schedule. If the claim is denied by the adjuster, you will be required to assume responsibility for the bills yourself or to obtain coverage from your health insurance carrier. 8. If you miss more than 3 days due to a work related injury, you must complete and file with your supervisor a Leave Request Form. On the fourth day of absence, your supervisor, office manager, or terminal manager will forward a copy of this form to the Benefits Office. Leave request forms can be found in the backyard at: 9. You must present a written release before you return to work from the designated provider. You cannot return to work until you have a written release from the designated provider.

6 What Should I Do If I Am Injured At Work? 1) In the case of a serious life or limb-threatening emergency, call 911 or go to the nearest hospital/trauma center! Followup care is to be arranged with one of the District s designated medical providers listed Concentra, Health One Occupational Medicine and Rehabilitation, Rocky Mountain Medical Group or US Health Works. 2) If the injury is not a serious emergency, you must contact the designated individual at your facility, complete a First Report of Injury, have your supervisor sign it and submit it to Risk Management. If you choose to be seen by a doctor you must select one of the District s designated medical providers listed below. You are not authorized to see your personal physician for a work related injury. Any costs for care by your personal physician will not be covered by the District s Workers Compensation program. Risk Management Contacts: Christine Baxter at or Sherry Mars at or us at riskmanagement@cherrycreekschools.org The Employer s First Report Of Injury must be filed through the Office of Risk Management in order for your bills to be paid through the District s Workers Compensation program. FAX the Employer s First Report Of Injury to or at riskmanagement@cherrycreekschools.org 3) You will be seen by the District s designated medical providers. You must select a designated provider from the list provided below: By Appointment/Walk In By Appointment/Walk In By Appointment/Walk In By Appointment/Walk In After Hours and Emergency ONLY CONCENTRA Dr. Diane Adams, DO E. Iliff Ave Aurora, CO M-F 8am-5pm -OR- Dr. Carrie Burns, MD E. Arapahoe Rd # M-F 8am-6pm HEALTH ONE OCCUPATIONAL MEDICINE AND REHABILITATION Dr. Matthew Lugliani, MD 1444 S Potomac St, #200 Aurora, CO OR- Dr. Robert Broghammer, MD Dr. Hiep Ritzer, MD E Arapahoe Rd, # M-F 7:00 AM 5:00 PM ROCKY MOUNTAIN MEDICAL GROUP Dr. Annu Ramaswamy, MD Dr. Brian Beatty, DO E. Mississippi Ave #120 Aurora, CO M-F 8:00 AM 5:00 PM U.S. HEALTH WORKS Dr. Nelson MD Dr. Rossi MD 8200 E. Belleview #428C Greenwood Village, CO M-F 8:00 AM 5:00 PM CENTENNIAL MEDICAL PLAZA E. Arapahoe Road Hours *In case of serious injury call 911 or go to the nearest medical facility. *You must follow up at Concentra, Health One, Rocky Mountain Medical Group or U.S. Health Works on the next business day after your ER visit. 4) It is your responsibility to inform the Office of Risk Management and your supervisor of your injury. 5) Questions? Call the Office of Risk Management, Christine Baxter at or Sherry Mars at We will help you through your injury and get you back to work!

7 CHERRY CREEK SCHOOL DISTRICT #5 AUTHORIZATION FOR MEDICAL TREATMENT OR EVALUATION Bring this document with you to the Work Comp Provider s Facility. EMPLOYEE S NAME DATE OF BIRTH DATE I.D. VERIFIED NOTICE AND ACKNOWLEDGEMENT Cherry Creek School District is self-insured with the Joint School District Workers Compensation Self Insurance Pool in conjunction with a third party claims administrator, Cannon Cochran Management Services, Inc. (CCMSI). Your employer contact is: Claims Administrator contact: Risk Management CCMSI 4850 S. Yosemite Street P.O. Box 4998 Greenwood Village, CO Greenwood Village, CO Karyn Fast, Risk Manager Ph: Ph: Fax: Christine Baxter, Risk Management Specialist Ph: Sherry Mars, Risk Management Specialist Ph: Fax: riskmanagement@cherrycreekschools.org I select the following provider I select the following provider NOTICE AND SELECTION OF PROVIDERS I select the following provider I select the following provider After Hours and Emergency ONLY CONCENTRA Dr. Diane Adams, DO E. Iliff Ave Aurora, CO M-F 8am-5pm -OR- Dr. Carrie Burns, MD E. Arapahoe Rd # M-F 8am-6pm HEALTH ONE OCCUPATIONAL MEDICINE AND REHABILITATION Dr. Matthew Lugliani, MD 1444 S Potomac St, #200 Aurora, CO OR- Dr. Robert Broghammer, MD Dr. Hiep Ritzer, MD E Arapahoe Rd, # M-F 7:00 AM 5:00 PM ROCKY MOUNTAIN MEDICAL GROUP Dr. Annu Ramaswamy, MD Dr. Brian Beatty, DO E. Mississippi Ave #120 Aurora, CO M-F 8:00 AM 5:00 PM U.S. HEALTH WORKS Dr. Nelson MD Dr. Rossi MD 8200 E. Belleview #428C Greenwood Village, CO M-F 8:00 AM 5:00 PM CENTENNIAL MEDICAL PLAZA E. Arapahoe Road Hours In case of serious injury call 911 or go to the nearest medical facility. You must follow up at Concentra, Health One, Rocky Mountain Medical Group or U.S. Health Works on the next business day after your ER visit. Signature: Date:

8 MILEAGE REIMBURSEMENT FORM Claim Number: Name: Employer: Cherry Creek School District Address: DATE FROM DESTINATION ROUND TRIP MILES PURPOSE TOTAL MILES: I certify that the statements in the above schedule are true and correct in all respects; that payment of the amounts claimed herein has not and will not be reimbursed to me from any other sources; that travel performed for which reimbursement is claimed was performed by me for medical treatment and that no claims are included for expenses of a personal or political nature or for any other expenses not authorized by Workers Compensation; and that I actually incurred or paid the operating expense of the motor vehicle for which reimbursement is claimed on a mileage basis. I am aware that I may be prosecuted for fraud if the information I have provided is falsely documented. Signature: Date: Total to be Reimbursed: (cents) per mile = $ after 1/1/14 Return to: CCMSI, P.O. Box 4998, Greenwood Village, CO 80155

9 WARNING IF YOU ARE INJURED ON THE JOB, WRITTEN NOTICE OF YOUR INJURY MUST BE GIVEN TO YOUR EMPLOYER WITHIN FOUR WORKING DAYS AFTER THE ACCIDENT, PURSUANT TO SECTION (1) AND (1.5), COLORADO REVISED STATUTES. IF THE INJURY RESULTS FROM YOUR USE OF ALCOHOL OR CONTROLLED SUBSTANCES, YOUR WORKERS COMPENSATION DISABILITY BENEFITS MAY BE REDUCED BY ONE-HALF IN ACCORDANCE WITH SECTION , COLORADO REVISED STATUTES.

10 AVISO SI SE LASTIMA EN EL TRABAJO, DEBE DARLE UN AVISO POR ESCRITO A SU EMPLEADOR DENTRO DE CUATRO DÍAS LABORABLES DEL ACCIDENTE, SEGÚN A LA SECCIÓN DE LOS ESTATUOS REVISADOS DE COLORADO (1) Y (1.5). SI EL ACCIDENTE RESULTA DEBIDO AL USO DE ALCOHOL O UNA SUSTANCIA CONTROLADA, SUS BENEFICIOS DE LA INCAPACIDAD DE LA COMPENSACIÓN DE LOS TRABAJADORES PUEDEN SER REDUCIDOS POR UN MEDIO EN ACUERDO DE LA SECCIÓN DE LOS ESTATUOS REVISADOS DE COLORADO 8-42