Workers Compensation Programs

Transcription

1 Workers Compensation Programs The Hartford s workers compensation program is built around networks of medical providers and facilities that help us ensure consistent and appropriate care for our customers injured employees. All network providers must meet high quality and credentialing standards, while negotiated contract rates help us make the very most of every health care dollar. Return to Work The Hartford uses the Team Work sm return-to-work approach, where the employer, injured worker, physician, adjuster, and nurse case manager focus on getting the injured worker back on the job as quickly as medically possible. We concentrate on an injured worker s abilities, finding those tasks of a job that he or she can do, or finding some other duty to get the worker back on the job. Faster return to work is an advantage for all involved, improving productivity, the worker s morale, and the overall claim outcome. Prescription Drug Program The Hartford s prescription drug program includes over 50,000 network pharmacies nationwide and provides retail pharmacy discounts and a simple process for filling prescriptions with no out-of-pocket costs to an injured employee. Our First Fill service allows injured workers to obtain a 10-day supply of medication before a claim has been established, while our home delivery program offers injured employees the convenience of obtaining maintenance medications by mail. Permanent Partial Disability (PPD) Our PPD program takes a comprehensive approach to analyzing a worker s injuries and ensuring that the PPD award is consistent with the statutory provisions in each state. Nurse case managers, trained in PPD review, use software to compare doctors ratings to American Medical Association guidelines and bring any inconsistency to the doctors attention for further consideration and possible revision. Large Loss Program When a work-related injury is traumatic, resulting in brain damage, paralysis or another lifechanging injury, The Hartford focuses on doing the right thing for the injured worker. This involves close coordination with the injured employee, his or her family, and regional and national treatment centers. These centers are experienced in workplace trauma and poised to provide the most appropriate care as quickly as possible. QMEDTRIX AND CPS Pricing Services The QMEDTRIX and CPS repricing tools help us determine and negotiate the most appropriate prices for non-network medical services, including hospital stays, ambulance transport, and durable medical equipment. The Hartford P&C CLAIMS 10/30/06

2 What to Do in the Event of a Work-Related Injury COMMERCIAL CLAIMS Prompt care, immediate loss reporting, and a focus on return-to-work are the keys to successful workers compensation claims. 1. Obtain appropriate medical care for the injured employee. Names and addresses of more than 400,000 network health care providers qualified to treat work-related injuries are available online at hartext or through our Network Referral Unit at (select 4 at the prompt). 2. Call The Hartford s Loss Connect Service at to report the claim as soon as possible. Claims professionals are standing by 24 hours a day, 365 days a year to take your call. A minute call can expedite the claim process by: - Gathering necessary information, eliminating the need for you to submit claims forms - Confirming details of the accident/injury to assign the appropriate claims adjuster - Forwarding any state required reports, if applicable, to the state and the employer 3. Help the injured employee get back to work. Keep in contact with the injured employee Get specific restrictions from the doctor Complete and return our Physical Demands Analysis form to help us understand the physical demands of the injured workers job Work with The Hartford to consider all options for returning the employee to work 4. Monitor the situation. Notify The Hartford of significant events: - Employee receives treatment outside the network - Employee retains an attorney - Employee doesn t cooperate with return-to-work plan - Employee returns to work Helping Injured Employees Get Back to Productivity The Hartford uses the Team Work sm return-to-work approach, where the employer, injured worker, physician, adjuster, and nurse case manager focus on getting the injured worker back on the job as quickly as medically possible. Since we began the Team Work program, we ve been able to decrease the average days lost to workplace injuries by two weeks. We concentrate on an injured worker s abilities, finding those tasks of a job that he or she can do, or finding some other duty to get the worker back on the job. Faster return to work is an advantage for all involved, improving productivity, the worker s morale, and the overall claim outcome. Printed in the U.S.A The Hartford, Hartford, CT

3 COMMERCIAL CLAIMS Reporting A Work-Related Injury To report a workplace injury, gather the facts and call The Hartford Loss Connect Service at When an employee is injured on the job, the first concern is getting him or her to appropriate medical care. After that, it is important to report the claim immediately. Research has shown that the sooner a claim is reported, the more accurate the claim outcome. Making the Call Because workers compensation claims tend to be complex, The Hartford needs to gather detailed information during the claim reporting call. Early understanding of the incident allows us to most effectively manage the claim, including care of the injured employee. Gathering the information listed below before the initial call will help speed the process. Company Information Account Number and Location Code (if applicable) Parent Company Name (or Program Name) Policy Number Do you have any reason to question this injury? What are the estimated number of days the employee will lose due to the injury? What is the anticipated date of return to work? Did anyone witness the accident? Who? Where was the injured employee treated (name, address, phone number of medical provider of facility)? Network Providers Names and addresses of more than 400,000 network providers qualified to treat work-related injuries are available online at or through our Network Referral Unit at (select 4 at the prompt). At the time of injury, our representatives can supply you with information on network providers in your area. Effect of Timely Reporting on Loss Costs Injured Worker Information Name, Date of Birth, Address, Phone Number Social Security Number Age, Gender Marital Status, Number of Dependants Hire Date, Years in Current Position Current Wage Information Details of Incident When was the accident reported to you and by whom (date, time)? Address where injury occurred? Type of injury (burn, cut, etc.)? Exact body part injured? What was the cause of the accident (slip & fall, struck by object, etc.)? 30% 25% 20% 15% 10% 5% 0% 0% incident day 6% 19% 22% week 1 week 2 weeks 3 & 4 Closed Claims, Accident Years Includes Medical Only and Lost Time Claims 30% 1 month or later Printed in the U.S.A The Hartford, Hartford, CT

4 Workers Compensation Fax/ Template Fax Reporting: Reporting: The following script contains the comprehensive list of questions for your loss report. Asterisks denote information that is critical to proper handling office assignment. Please be sure to obtain this information prior to calling in a claim. Preparer Information 1. Preparer Name: 3. Filing State: * 5. Date of Loss: * 7. Employee s Full Name: * 9. Is this a longshoreman claim: Yes No Employer/Loss Location Information 2. Preparer Phone: 4. Preparer s Title: 6. Time of Loss: 8. Employee Social Security Number: 10. Policy Number: * 11. Account Number: * 12. Location Code: Account Name: Employer Name: 15. Address: City: State: Zip Code: 16. Contact Work Phone: 17. FEIN: 18. Mailing Address: 19. Accident Location Name: 20. Address: City: State: Zip Code: 21. Is this the employer s premises? (check one) Yes No Employee Information 22. Employee Address: City: State: Zip: 23. Home Phone: 24. Work Phone: 25. Alt Phone: 26. Date of Birth: 27. Age: 28. Gender: 29. Marital Status: Number of Dependent: Primary Language: 32. Regular Department: 33. Regular Occupation: 34. EE injured in regular job Y/N/U: 35. NCCI Code: Worker s Compensation Fax Template Page 1 of 5

5 36. Check Correct Answer For Each: Is Employee a Partner: Yes No Owner: Yes No Officer: Yes No 37. Supervisor s Full Name: 38. Supervisor Phone: Employment Information If you answered 39, disregard 41/If you answered 42, disregard 43/ Only answer 1 of # Date of Hire: 42. Date in Job: 45. (Answer if EE is temp/seasonal or 46. terminated) Job End Date: Hours Per Day: Pay Type: Hourly Wage : Daily Wage: Weekly Wage: 53. Gross Wages 30 days prior to accident: ( AZ only) 54. Time Shift Begins: 40. State of Hire: 43. Length in Current Job: 55. Time Shift Ends: 41. Length of Employment: 44. Employment Status: 47. Days Per Week: 52. Monthly Wage: 56. Regular Days Off (check): Mon Tues Wed Thurs Fri Sat Sun 57. Other Payments Not Reported: 60. Does Employee Consistently Receive Overtime: 63. Date Injury Reported to Employer: 58. Amount: 61. Amount: 65. Date claim form provided to employee: (CA only) Loss Information 66. Loss Description (what was employee doing at time of injury): 59. How Often is Other Payment Received: (Monthly, weekly, other) 62. How is Overtime Payment Paid: (Monthly, weekly, other) 64. Employee Status at Time of Reporting: (CA only) 67. Nature of injury: 68. Fatality Date: Previously Reported Claims If answer to 69 is YES please answer 70-72, if NO skip to # Has Employee previously reported a claim: 71. Status (open/closed): Injury Information (Current injury descriped in #66) 70. Loss Date: 72. Body Part Injured: 73. Has Employee missed time from work, or are they expected to? Yes No Unk 74. If so how many days?: 75. Has Employee returned to work: Yes No Unk 76. Date returned or expected to return: 78. Did EE return to regular or transitional duty: 80. Does employee have a Group Health Provider: (OR only) Yes No Unk Worker s Compensation Fax Template Page 2 of Total estimated # of days lost: 79. Did Employee receive medical treatment: Yes No Unk 81. If yes, name of Group health provider:

6 82. Fifth day incapacity date: (MA only) Lost Time Information (Answer #83-88 if EE is missing time from work, if NO disregard) 83. Last Day Worked: 86. First day missed: 84. Time EE left work: 87. Did salary continue: Initial Treatment Information (Answer if Treatment was received) 89. Initial Treatment (first aid/clinic/er): 90. Taken by Emergency Transportation? Yes No Unk Facility Name: Admitted to Hospital: Yes No Unk Worker s Compensation Fax Template Page 3 of Paid in full for date of inj?: 88. Late day EE paid in full: 91. Airlifted/Medivac? Yes No Unk Phone: Address: City: State: Zip Code: 95. Facility Type (clinic/hospital): 96. Treating Physician: 97. Type of Medical Treatment Received: 99. Date Admitted: 101. Intensive Care Unit: Yes No Unk Additional Treatment (Answer iff EE was referred or had follow -up) 103. Physician Name: Still in Hospital: Yes No Unk 102. Burn Unit: Yes No Unk Address: City: State: Zip Code: 105. Phone: 106. Specialty Type: 107. Type of Medical Treatment Received or Expected: Incident Information 108. Time Employee Began Work: 110. Department Where Injury Occurred: 109. Time Incident Reported: 111. Were Safeguards or Safety Equipment provided: Yes No Unk 112. Were Safeguards or Safety Equipment Used: Yes No Unk 113. Is the purpose of this claim a possible Dispute? (LA only) Yes No Unk 115. Labor and Industrial claim number: (WA only) 117. Could the employee have prevented the Accident: (VT only) Additional Incident Information 119. Was a Machine Part Involved: Yes No Unk 121. In What Way Was the Machine Defective: 122. Is The Claim Questionable: Yes No Unk 124. Was Employee Engaged in an 114. OSHA log Number: (UT only) 116. UBI Number (WA only) 118. Could the employer prevent this type of accident: (VT only) 120. Was Machine Part Defective: Yes No Unk 123. Was Employee Engaged in an Unsafe Activity: Yes No Unk 125. Describe Unsafe Activity:

7 Unsafe Activity: Yes No Unk Responsible Party (if applicable) 126. Responsible Party Name: 127. Phone: 128. Address: City: State: Zip Code: Witness Information (if applicable) 129. Witness Name: 130. Address: City: State: Zip Code: 131. Home Phone: 132. Work Phone: 133. Alt Phone: Contact Information 134. Name: 135. Address: City: State: Zip Code: 136. Work Phone: 137. Alt Phone: 138. Fax Number: Address: 140. Contact Person s Title: 141. When To Contact: Additional Information Jurisdictional Information (Submit only for applicable states) Nevada 142. How is employee paid: (check one) Bi-weekly Monthly Semi-monthly Weekly Other 143. Day of week pay period ends: (check one) Sun Mon Tues Wed Thurs Fri Sat Are scheduled days off rotating: Yes No If part time, how many hours a week was Unk the employee hired: hrs 146. How many months has the employee been Employed by the current employer in NV: months 147. OSHA log number: Worker s Compensation Fax Template Page 4 of 5

8 148. Was more than one person injured in the Accident: Yes No Unk 150. Was employee in your employ when the injured or disabled by occupational disease? Yes No 152. Will you have light duty work available if necessary: Yes No 154. Unemployment Compensation received during last 12 months: Yes No New Hampshire 156. Is a NH youth employment certificate on file: Yes No 158. Number of full time employees: 160. Is there a written safety program: Yes No 162. Managed Care Program: Yes No 149. Supervisor that injury or occupational disease was reported to: 151. Did employee return to next scheduled shift after accident: Yes No 153. Last day wages earned: 155. If validity of claim is doubted, state reason: 157. Estimated length of disability: 159. Number of part time employees: 161. Is there an active Safety Committee: Yes No 163. If yes, Managed care provider name: Texas 164. Does Employee speak English: Yes No 165. If no, native language: French German Italian Polish Russian Spanish Vietnamese Korean Other Unknown 166. Race: Asian Black White Hispanic 167. Tax ID number: 169. Last pay period hours worked: 171. Accident prevention services requested in past 12 months: Yes No 168. Last paycheck amount: 170. Last pay period days worked: 172. If yes, Accident prevention services received: Yes No Worker s Compensation Fax Template Page 5 of 5

9 COMMERCIAL CLAIM Workers Compensation Claim Center Locations Best Outcomes For Your Business Aurora: Address: 4245 Meridian Parkway, Aurora, IL Mailing Address: P.O. Box 400, Shawnee Mission, KS Toll-Free: FAX: Satellite Office to our Kansas City Workers Compensation Claim Center Baltimore: Address: Center Pointe Building, Shawan Center, 200 International Circle, Hunt Valley, MD Mailing Address: P.O. Box , Lake Mary, FL Toll-Free: FAX: Satellite Office to our Orlando Workers Compensation Claim Center Charlotte: Address: David Taylor Drive, Suite 200, Charlotte, NC Mailing Address: P.O. Box , Lake Mary, FL Toll-Free: FAX: Satellite Office to our Orlando Workers Compensation Claim Center Hartford: Address: 55 Farmington Avenue, Suite 301, Hartford, CT Mailing Address: P.O. Box 4771, Syracuse, NY Toll-Free: FAX: Satellite Office to our Syracuse Workers Compensation Claim Center Houston: Address: 785 Greens Parkway, Suite 210, Houston, TX Mailing Address: P.O. Box 4626, Houston, TX Toll-Free: FAX: Covering: AR, AZ, CO, LA, ID, MT, NM, OK, TX, UT, WY Kansas City: Address: 7300 West 110th Street, Overland Park, KS Mailing Address: P.O. Box 400, Shawnee Mission, KS Toll-Free: FAX: Covering: IA, IL, IN, KS, KY, MI, MN, MO, ND, NE, OH, SD, WI Orlando: Address: 200 Colonial Center Parkway, Suite 500, Lake Mary, FL Mailing Address: P.O. Box , Lake Mary, FL Toll-Free: FAX: Covering: AL, FL, GA, MD, MS, NC, SC, TN, VA, WV, District of Columbia

10 Sacramento: Address: Foundation Place, Rancho Cordova, CA Mailing Address: P.O. Box 13835, Sacramento, CA Toll-Free: FAX: Covering: AK, CA, HI, OR, WA Syracuse: Address: One Park Place, 300 South State Street, 7th Floor, Syracuse, NY Mailing Address: P.O. Box 4771, Syracuse, NY Toll-Free: FAX: Covering: CT, DE, MA, ME, NH, NJ, NY, PA, RI, VT Workers Compensation ClaimXchange Centers Information For Medical Only Claim Handling Aurora: For AL, AK*, CA, FL, GA, IA, IL, IN, KS, KY, MI, MN, MO, MS, ND*, NE,OH, OR*, SC, SD, WA, WI: Mailing Address: P.O. Box 7957, Wheaton, IL Toll-Free: Syracuse: For AR, AZ*, CO, CT, DE, ID*, LA, MA, MD, ME, MT*, NC, NH, NJ, NM, NY, NV, OK, PA, RI, SC, TN, TX, UT, VA, VT, WV, WY, District of Columbia: Mailing Address: P.O. Box 4747, Syracuse, NY Toll-Free: For Medical Bill Submissions For CA, FL, NJ, TX: Mailing Address: P.O. Box 14187, Lexington, KY For billing inquiries: FAX: For All Other States: Mailing Address: P.O. Box 14170, Lexington, KY For billing inquiries: FAX: Note: Nevada claims are handled by Specialty Risk Services, 750 E. Warm Springs Road, Suite 220, P.O. Box 2, Las Vegas, NV Phone: FAX: * Medical only claims for these designated states are handled in-state by adjusters reporting to our Workers Compensation Claim Centers. Washington and Ohio medical only claims are handled by the State Boards. Hawaii claims are handled in our Hawaii Claim Office, 1001 Bishop Street, Suite 1700, Pauahi Tower, Honolulu, HI Phone: FAX: (P) 6th REV Printed in U.S.A The Hartford, Hartford, CT 06115

11 Network Referral Unit What is a Workers Compensation medical network? A medical network is an organization that has ready access to physicians, hospitals and other medical care providers who have experience treating workers compensation related injuries. It also helps you manage the cost associated with these injuries. The Hartford has contracted with medical networks across the United States to provide this service to our workers compensation customers. What is the Network Referral Unit? The Hartford s Network Referral Unit (NRU) helps you identify the appropriate medical care providers in your area. The NRU will provide you with the immediate information by telephone or by mailing or faxing a list of providers. Please be sure to post the list where all employees will have access to it. When should you contact the Network Referral Unit? Now. Even before one of your employees is injured, we urge you to get a listing of approved medical providers in your area. In case of an injury, you will know who to call to get your employee immediate and appropriate medical attention. How do you use the Network Referral Unit Services? Call You will need to provide the network referral analyst with a complete address of your work location so he/she can identify a medical provider. Employees also have the option to seek a referral where they live. If you have questions regarding a specific claim or rules that govern use of network providers, contact your local Hartford claim office. The Hartford s Network Referral Unit Call At the prompt PRESS 2 At the next prompt PRESS 4 Monday through Friday 7 a.m. to 6 p.m. CST th Rev Printed in the U.S.A The Hartford, Hartford, CT 06115

12 The Hartford s Regional Medical Program Consultants Best outcomes for your business helping our customers manage workers compensation claims through the use of preferred medical network providers and a national pharmacy program Carol Doerge Reid Nelson Ryan Harris Jeanette Sanger Cyndee Smith Southwest WC Claim Center Northbelt II, Suite Greens Parkway Houston, TX Western WC Claim Center Foundation Place Gold River, CA Central WC Claim Center 7300 West 110th Street Overland Park, KS Southeast WC Claim Center 200 Colonial Center Parkway Lake Mary, FL Northeast WC Claim Center One Park Place 300 South State Street, 7th Floor Syracuse, NY Phone: x73874 Fax: [email protected] Territory: AR, AZ, CO, ID, LA, MT, NM, NV, OK, TX, UT, WY Phone: Fax: [email protected] Territory: AK, CA, HI, OR, WA Phone: x31218 Fax: [email protected] Territory: IA, IL, IN, KS, KY, MI, MN, MO, NE, ND, OH, SD, WI Phone: x23624 Fax: [email protected] Territory: AL, DC, FL, GA, MD, MS, NC, SC, TN, VA Phone: x55167 Fax: [email protected] Territory: CT, DE, MA, ME, NJ, NH, NY, PA, RI, VT The Hartford P&C Claim 2/22/2007

13 COMMERCIAL CLAIM RX Program Best Outcomes For Your Business Pharmaceutical expenses comprise a significant portion of workers compensation costs. The Hartford offers TMESYS TM, a pharmacy benefit management program (PBM) of Pharmacy Corporation of America to enable its customers to manage these costs while providing timely and efficient pharmaceutical services to their injured workers. Consider these benefits of The Hartford s PBM program: The Hartford s Services Meet Customer Needs An automatic and simple process for injured workers that does not require a prescription ID card or claim/authorization forms. A payment process that is virtually transparent to the injured worker meaning no out-of-pocket costs to the employee. Pharmacy Capabilities Connection to TMESYS, with 24-hour access to our database of claimants. Online prescription review at point of service (prior to dispensing medications). Online claim eligibility verification. Electronic submission of claims to TMESYS. Around-the-clock customer support desk availability, 365 days per year. Important Workers Compensation Enhancements Retail pharmacy discounts. Permissible generic drug substitution (in place of more costly name brand medications). Point-of-service prescription review. The voluntary program is simple to use. Employees inform their pharmacists that the prescriptions are for work-related injuries and supply their name and social security number. Initial Prescriptions Filled Quickly through First Fill* First Fill, a component of The Hartford s PBM, enables injured workers to obtain up to a 10-day supply of first prescriptions before the claim has been established. Many work-related injuries occur outside the usual nine-to-five schedule and this program helps those injured workers fill prescriptions without delay. Through First Fill, employees avoid out-of-pocket costs for injury-related medications. To qualify: The prescription must be written within 30 days from the date of injury. Medication must be included in The Hartford s formulary. A pharmacy within the TMESYS network must be used. *First Fill is available in all states, except Delaware and Hawaii (S) 2nd REV Printed in U.S.A The Hartford, Hartford, CT 06115

14 The Hartford Injured Worker s Prescription Information Sheet TAKE TO PHARMACY//LLEVAR A LA FARMACIA Injured Worker Name: Social Security #: Date of Injury: Dear Injured Worker, We want you to be able to get your worker s compensation prescription drugs when you need them and at the pharmacy of your choice. Please give this notice to your pharmacy. The pharmacies listed below participate in the Tmesys pharmacy network and will expedite the processing of your approved Worker s Compensation prescriptions, based on the established parameters by The Hartford. Apreciado Trabajador Lesionado, Queremos que usted pueda obtener sus prescripciones de compensación de trabajador lesionado cuando las necesite y en la farmacia de su opción. Por favor, muestre este aviso en su farmacia. Las farmacias que aparecen en la siguiente lista participan en la red de farmacias de Tmesys, las cuales acelerarán el procesamiento de sus prescripciones aprobadas de compensación de trabajador lesionado, basadas en los parámetros establecidos por su compañía de seguros de compensación de trabajador lesionado, The Hartford. Dear Pharmacist, Please call the Tmesys TM Pharmacy Help Desk, , to establish First Fill eligibility and obtain the ID# necessary for the online processing of Worker s Compensation medication for this newly injured worker. Please contact the Tmesys TM Pharmacy Help Desk and inform the Tmesys TM Help Desk Representative that there is a newly injured worker at your pharmacy filling a Hartford First Fill prescription. Sincerely/Sinceramente, Tmesys, Inc. ALL PARTICIPATING PHARMACIES HAVE NOT BEEN INCLUDED ON THIS LIST. PLEASE CALL The Hartford s Network Referral Unit at (800) / prompt 4 TO OBTAIN A LISTING OF OTHER PARTICIPATING PHARMACIES IN YOUR AREA. CHAIN NAME INDEX NAME CHAIN NAME INDEX NAME CHAIN NAME INDEX NAME CHAIN NAME INDEX NAME A & P index: TYS Giant Pharmacy TMESYS Milex Drugs code: Satan Shop-Rite TYS Arbor Drug Carrier code: TI Goodings TME index D, bill code TME Milner-Rushing Drugs compensation as Tom Ashley Stop N Shop 146 Bartell Drug Index: TMS Hannaford Food & Drug index: TYS National Supermarkets use "Separate Plan Number" Super D Plan name:332 Big B index: TYS Happy Harry's index:tme NOB Hill Phcy plan: TMESYS Super Valu carrier code: TYS Biggs Carrier code: TYS Harco Phcy index: TYS Pathmark Pharmacy TYS Super X (HSI) index: TME Bi-Lo Pharmacy input code: TMS Hi-School Pharmacy TMESYS Central Billing code:tm01 Perry Drg Str index:ts Thrift Drug carrier code: 4139 Bi-Mart index: TMESYS HEB Phcy price code:t9 Phar-Mor TYS Thriftway Pharmacy 2066 Brooks Drugs Code: TME Hooks, Brooks& Super X(HIS) index: TME Pic & Save plan name: T or TMESYS Tom Thumb Phcy pdx code: TMS Brookshire Brothers Condor Code: 2050 Horizon Pharmacy TYS Prevo Drugs input code: TS Tops Pharmacy access code: TI Cardinal Health index: Call support HyVee Drugtown index:bin # in 3rd party set up Publix carrier:tme plan: SYS or TYS Tri Daly Drugs Carrier code: TMS Cub Pharmacy Carrier Code: TYS J & J Pharmacy TCS Raley's/Bel Air Phcy plan: Tmesys Turner Drugs Index: Tmesys CVS Drugs Condor Code: 8822 Joel & Jerry's index: TME Randalls Pharmacy TMSRX Twin Value carrier code:tys Drug Emporium TYS K & B Plan code:tmesys Revco drugs TMWC U-Save index: TME Drug Fair index: TMESYS Kash N Karry plan: TYS Rite-Aid drugs TMESYS United TYS Duane Reade TMESYS Kerr Drugs TMESYS RX Discount Pharmacy input code:tme Vons carrier: TME Eckerds(FL) Termimal plan:2802(fl) K-mart phcy Carrier code: TYS Sack-n-Save plan#: 6012 or 5097 VIX Pharmcay carrier code: TME Eckerds(all others) Termimal plan:2801 Kroger Phcy index: TS,TM,YS Safeway Phcy processor code: TME or TYS Walgreens carrier code: TMEWC Franck's Pharmacy price code: TM Laverdiere's plan name: TMESYS Sav-A-Lot 60 Wal-Mart phcy carrier: TME Fred Meyer TYS Lifecheck Drug TMESYS Sams Club Pharmacy carrier code: TME Wegman Pharmacy carrier code: TME Fred's Pharmacy TMESYS Long's Phcy plan: #1,TMES Save Mart Carrier code: TYS Weis Markets carrier code: TYS Genovese Now Eckerd Drugs! Medicine Shoppe varies by each store system Shopko Pharmacy TYS Winn-Dixie index: TME (plan 2066) Giant Eagle Pharmacy index:tme (Do not use WC plan Medistat Phcy Condor code: 2425 Shop N Save carrier code: TYS Employer Name:

15 INNOVATIVE CLAIM SOLUTIONS Save Time and Money With Team WorkSM Learn how The Hartford s ground-breaking Return-To-Work program can improve productivity, lower your workers compensation losses and give new meaning to Get Well Soon. QUICK FACTS STUDIES SHOW EMPLOYEES WHO ARE OUT OF WORK MORE THAN 12 WEEKS HAVE LESS THAN A 50% CHANCE OF EVER RETURNING. WHAT S A DAY WORTH? LOST WORK TIME COSTS EMPLOYERS $72 PER DAY, AND THAT DOESN T INCLUDE MEDICAL COSTS. OUR WORK- ERS COMPENSATION CUS- TOMERS FIND THAT, WITH TEAM WORK, THEIR INJURED EMPLOYEES RETURN TO WORK AN AVERAGE OF EIGHT DAYS EARLIER! WITH TEAM WORK, THOSE EIGHT DAYS COULD SAVE YOUR BUSINESS MORE THAN $576 PER INJURED WORKER. IMPACT ON PREMIUM 70%-80% OF WORKERS COMPENSATION CLAIM COSTS IMPACT YOUR ULTIMATE PREMIUM. This document provides an overview of coverages and services. Coverages may differ in availability by state. All coverages are individually underwritten. For a complete description of all coverages, terms and conditions, refer to the insurance policy. In the event of a conflict, the terms, conditions and exclusions of the policy prevail. Team Work A Can Do Attitude in Action The Hartford s Team Work program is based on the fundamental belief that every one of your injured workers is a valuable resource and will return to productive employment with you. The three key components of our innovative Team Work program focus on saving your business time and money while facilitating appropriate return to work. 1. Collaborative approach Early on, a claim professional brings together all the critical resources, such as your risk manager or supervisor, medical provider, and our nurse care managers and loss control experts, to achieve optimal outcomes. 2. Focus on abilities versus disabilities After an injury, an employee may not be able to return to the same job, but he or she might be able to do something else that uses different skills. That s what ability management is all about identifying and offering meaningful alternatives that will keep a worker productive, engaged and involved, such as part-time work or temporary assignments. 3. The employee returns to work In most claims, the employee is able to return to their prior duties. However, in the unlikely event that an employee may not be able to return to the same job, we will assist your efforts in identifying alternative positions which utilize different skills so that the employee remains a valuable resource and asset to your organization. Benefits at a Glance Reduction in Lost Work Time Positively impact your cost of doing business by getting injured employees back to work sooner and helping them to be productive as they recover. Employee Satisfaction and Retention Your people are your greatest asset. An employee who feels valued is more productive, dedicated and delivers quality results that contribute to your company s success. Faster Recovery and Better Outcomes for Everyone Working together and supporting a productive, return-to-work focus benefits everyone and leads to increased employee satisfaction. To learn more about how The Hartford s Team Work approach to workplace injury can help speed your employee s return to work, improve your productivity, and reduce your disability costs, call your Hartford representative today and speak with your claim service consultant, or visit us on the Web at Printed in U.S.A The Hartford, Hartford, CT 06115

16 Physical Demands Analysis Employee Employer Claim Number Job Title Date of Injury I. Employee works how many hours per day? How many days per week? How many hours per day is the employee required to: Sit ; Stand ; Walk ; Drive II. How often during the work day does the employee have to Lift/Carry, Never Occasionally Frequently Constantly (0-33%) 1-3 Hr (34-66%) 4-6 Hr (67-100%) 6-8 Hr 1 10 lbs lbs lbs lbs. over 100 lbs. III. How often during the work day does the employee have to Push/Pull Never Occasionally Frequently Constantly (0-33%) 1-3 Hr (34-66%) 4-6Hr (67-100%) 6-8Hr 1 10 lbs lbs lbs lbs. over 100 lbs. IV. How often must the employee perform the following? (N=Never, O=Occas, F=Freq, C=Const) Climbing Crouching Grasping Balancing Crawling Overhead lifting Bending Reaching Work on ladders Stooping Handling Feeling Kneeling Fine Manipulation Keying V. Is repetitive use of the feet required? Right: yes/ no ; Left: yes/no Is repetitive use of the hands required? Right: yes/ no ; Left: yes/no VI. Does the employee work in any environmental conditions which may be a problem (e.g., temperature extremes, hazards, moving machinery, etc.)? If so, please list them: VII. Are you able to accommodate transitional duty? yes/ no Part time work? yes/no If yes, what does it involve? Signed: Title: Date: Please fax completed form to Attn: Fax: Thank You ** CONFIDENTIALITY NOTICE** The information contained in this facsimile message and/or the document transmitted are confidential medical records & intended only for the use of the individual or entity named above. If the reader of this message is not the intended recipient or agent responsible to deliver it to the intended recipient, you are hereby notified that any examination, use, dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify us by telephone at the above number and return the original message to us at the above address via the U.S. Postal Service. Thank you.

17 FAX Date Number of pages including cover sheet To Phone Fax Phone Employee Claim # Date of Injury Date of Birth From Address Phone Fax Phone CC: REMARKS: Urgent For your review Reply ASAP Please Comment Attached is a form addressing this injured worker s regular job duties. Please complete this form specifying the physical demands of his/her job. This information will then be presented to the injured worker s treating physician to help coordinate an early and safe return to work. Please be sure to indicate if transitional duty is available. We will keep you informed of the progress of your employee. If you have any questions regarding this form please contact me at the above number. Thank you for your cooperation. ** CONFIDENTIALITY NOTICE ** The information contained in this facsimile message and/or the document transmitted are confidential medical records & intended only for the use of the individual or entity named above. If the reader of this message is not the intended recipient or agent responsible to deliver it to the intended recipient, you are hereby notified that any examination, use, dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify us by telephone at the above number and return the original message to us at the above address via the U.S. Postal Service. Thank you.

18 Physical Capabilities Evaluation Employee Employer Claim Number Job Title Date of Injury I. How many hours can the patient work per day? How many days per week? How many hours per day is the patient able to: Sit ; Stand ; Walk ; Drive II. How often during the work day is the patient able to Lift/Carry: Never Occasionally Frequently Constantly (0-33%) 1-3 Hr (34-66%) 4-6 Hr (67-100%) 6-8 Hr 1 10 lbs lbs lbs lbs. over 100 lbs. III. How often during the work day is the patient able to Push/Pull: Never Occasionally Frequently Constantly (0-33%) 1-3 Hr (34-66%) 4-6Hr (67-100%) 6-8Hr 1 10 lbs lbs lbs lbs. over 100 lbs. IV. How often during the workday may the patient perform the following? (N=Never, O=Occas, F=Freq, C=Const) Climbing Crouching Grasping Balancing Crawling Overhead lifting Bending Reaching Work on ladders Stooping Handling Feeling Kneeling Fine Manipulation Keying V. Can the patient use his/her feet repetitively? Right: yes/ no ; Left: yes/no Can the patient use his/her hands repetitively? Right: yes/ no ; Left: yes/no VI. Does the patient have any additional restrictions of an environmental nature (e.g., temperature extremes, hazards, moving machinery, etc.)? If so, please list them: VlI. Has the patient reached maximum medical improvement: yes/ no ; If Yes, Rating Date patient can return to work at his/her regular occupation: Date patient can return to work in a transitional duty capacity: If so, please provide any additional restrictions: Signed: Print Name: Date: Please fax completed form to Attn: Fax: Thank you ** CONFIDENTIALITY NOTICE ** The information contained in this facsimile message and/or the document transmitted are confidential medical records & intended only for the use of the individual or entity named above. If the reader of this message is not the intended recipient or agent responsible to deliver it to the intended recipient, you are hereby notified that any examination, use, dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify us by telephone at the above number and return the original message to us at the above address via the U.S. Postal Service. Thank you.

19 FAX Date Number of pages including cover sheet To: Phone Fax Phone Employee Claim # Date of Injury Date of Birth From Address Phone Fax Phone CC: REMARKS: Urgent For your review Reply ASAP Please Comment Dear Dr. Please see the attached forms. The Physical Demands Analysis form has been completed by the employer and describes the injured employee s regular job duties. The Physical Capabilities Evaluation form is for your completion. Please identify the injured employee s current work ability. When completed, please sign and fax to me at the above number. Thank you for your assistance. ** CONFIDENTIALITY NOTICE ** The information contained in this facsimile message and/or the document transmitted are confidential medical records & intended only for the use of the individual or entity named above. If the reader of this message is not the intended recipient or agent responsible to deliver it to the intended recipient, you are hereby notified that any examination, use, dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify us by telephone at the above number and return the original message to us at the above address via the U.S. Postal Service. Thank you.