RISK MANAGEMENT MEMORANDUM

RISK MANAGEMENT MEMORANDUM TO: FROM: Cherry Creek School District Employees Karyn Fast, Risk Manager Georgia Steele, Risk Management Specialist DATE: August 3, 2015 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, should be directed to Georgia Steele at 720-554-4644 or Karyn Fast at 720-554-4643, Fax 720-554-4641. 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 forms. 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. /gs Attachments cc: Guy G. Bellville, Chief Financial Officer

Cherry Creek School District Worker s 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 provided. 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 three corporation medical providers listed below where you want to receive treatment for your work related injury. Follow-up care, after receiving emergency medical treatment, must be provided by a designated physician the next day. The District has designated Arbor Occupational Medicine Center, Rocky Mountain Medical Group and Health One Occupational Medicine and Rehabilitation at the following locations, 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 bring the form with you to present at the facility you have chosen from the list below. Arbor Occupational Medicine Arbor Occupational Medicine Center 8200 E. Belleview, Suite 428C Dr. Koval, M.D. Greenwood Village, CO 80111 Phone: 303-741-1166 Hours: 8am 5pm, M-F Rocky Mountain Medical Group Rocky Mountain Medical Group 13650 E. Mississippi Ave, Suite 120 Dr. Annu Ramaswamy, M.D. Aurora, CO 80012 Dr. Brian Beatty, D.O. Phone: 720-748-7072 Hours: 8am - 5pm, M-F Health One Occupational Medicine and Rehabilitation Health One Occupational Medicine 1444 S Potomac St, #200 Dr. Braden Reiter, D.O. Aurora, CO 80012 Dr. Matthew Lugliani, M.D., MPH Phone: 303-214-0000 Hours: 7am - 5pm, M-F

Health One Occupational Medicine 14000 E Arapahoe Rd, #160 Dr. Hiep Ritzer, MD Centennial, CO 80112 Phone: 303-218-4250 Hours: 7am - 5pm, M-F After Hours and Emergency Care Centennial Medical Plaza 14200 E. Arapahoe Road After Hours and Emergency Room Only Centennial, CO 80112 Phone: 303-699-3000 Rose Medical Center 4567 E. 9th Ave After Hours and Emergency Room Only Denver, CO 80220 Phone: 303-320-2121 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 (Telephone Number: 720-554-4644) by the following work day so that a designated physician can be assigned to your case. 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 The District has established a Preferred Provider Program for the purchase of prescription drugs with National Pharmaceuticals Services (NPS). An initial 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. NPS will bill our Workers Compensation third party administrator directly. 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 (66-2/3%) 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. Your Responsibilities As an employee of the District you have certain responsibilities in your Workers Compensation claim. Your responsibilities are as follows: 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 8-43-404 (5) (a), you can select from the list of three corporate medical providers designated by the District (Arbor Occupational Medicine, 8200 E. Belleview, Suite 428C, Greenwood Village, CO 80111 or Rocky Mountain Medical Group, 13650 E. Mississippi Ave., Suite 120, Aurora, CO 80012 or Health One Occupational Medicine and Rehabilitation, 1444 S Potomac St., #200 Aurora, CO 80012 and 14000 E Arapahoe Rd, #160, Centennial, CO 80112) for treatment of your work related injury. Emergency life and limb threatening treatment should be obtained at the nearest medical facility and follow-up care will 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 will forward a copy of this form to the Benefits 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 with the District s self-insurance pool handling your claim.

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! Follow-up care is to be arranged with one of the District s designated medical providers listed Arbor, Rocky Mountain and Healthone. 2) If the injury is not a serious emergency, you must contact the Office of Risk Management, Georgia Steele, at 720-554-4644 or gsteele2@cherrycreekschools.org and/or your school nurse to make arrangements to see one of the District s designated medical provides 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. The Office of Risk Management or your school nurse can assist you with scheduling your appointment and completion of the necessary paperwork. 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 720-554-4641. 3) Notify your supervisor. 4) 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 After Hours and Emergency ONLY ARBOR OCCUPATIONAL MEDICINE 8200 E. Belleview, Suite 428C Greenwood Village, CO 80111 303-741-1166 M-F 8:00 AM 5:00 PM Dr. Jeff Raschbacher, MD Dr. Koval, MD ROCKY MOUNTAIN MEDICAL GROUP 13650 E. Mississippi Ave, Suite 120 Aurora, CO 80012 720-748-7072 M-F 8:00 AM 5:00 PM Dr. Annu Ramaswamy, MD Dr. Brian Beatty, DO HEALTH ONE OCCUPATIONAL MEDICINE AND REHABILITATION 1444 S Potomac St, #200 Aurora, CO 80012 303-214-0000 Dr. Braden Reiter, DO Dr. Matthew Lugliani, MD or 14000 E Arapahoe Rd, #160 Centennial, CO 80112 303-218-4250 M-F 7:00 AM 5:00 PM Dr. Hiep Ritzer, MD CENTENNIAL MEDICAL PLAZA 14200 E. Arapahoe Road Centennial, CO 80112 303-699-3000 24 Hours ROSE MEDICAL CENTER 4567 E. 9 th Ave. Denver, CO 80220 303-320-2121 *You must follow up at Arbor, Rocky Mountain or Healthone the next business day after your ER visit. 5) It is your responsibility to inform the Office of Risk Management and your supervisor of your progress and any time you are off work. Workers Compensation will not pay for time off work that is not authorized by one of the District s designated medical providers. If you cannot return to your regular duties, alternative duties may be temporarily assigned. Questions? Call the Office of Risk Management, Georgia Steele, at 720-554-4644. We will help you through your injury and get you back to work!

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 7600 East Orchard Road, Suite 360N Greenwood Village, CO 80111 Greenwood Village, CO 80155 Karyn Fast, Risk Manager Ph: 303.804.2000 Ph: 720.554.4643 Fax: 303.804.2005 Georgia Steele, Risk Management Specialist Ph: 720.554.4644 Fax: 720.554.4641 NOTICE AND SELECTION OF PROVIDERS I choose the below facility for treatment ARBOR OCCUPATIONAL MEDICINE 8200 E. Belleview, Suite 428C Greenwood Village, CO 80111 303-741-1166 M-F 8:00 AM 5:00 PM Dr. Koval, MD I choose the below facility for treatment ROCKY MOUNTAIN MEDICAL GROUP 13650 E. Mississippi Ave, Suite 120 Aurora, CO 80012 720-748-7072 M-F 8:00 AM 5:00 PM Dr. Annu Ramaswamy, MD Dr. Brian Beatty, DO I choose the below facility for treatment HEALTH ONE OCCUPATIONAL MEDICINE AND REHABILITATION 1444 S Potomac St, #200 Aurora, CO 80012 303-214-0000 Dr. Braden Reiter, DO Dr. Matthew Lugliani, MD or 14000 E Arapahoe Rd, #160 Centennial, CO 80112 303-218-4250 M-F 7:00 AM 5:00 PM Dr. Hiep Ritzer, MD Signature: Date:

MILEAGE REIMBURSEMENT FORM Claim Number: Name: Employer: Cherry Creek School District Address: Carrier #: 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: Miles @.53 (cents) per mile = $ after 1/1/14 Return to: CCMSI, P.O. Box 4998, Greenwood Village, CO 80155

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 8-43-102(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 8-42-112.5, COLORADO REVISED STATUTES

Translation of: Notice to Employer of Injury Poster 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 8-43-102(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 8-42-112.5.