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 Texas state-mandated forms and a step-by-step process to follow in case of 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 Irving, Texas. 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 Texas workers compensation process. The following state forms have been included in your claims kit packet: 1. Texas Form DWC-001 First Report of Injury (FROI)- If a specific injury results in at least one (1) day of lost time, the employer must file this form within eight (8) days after receiving notice of a disability or death (oral or written). In cases involving an occupational disease, the employer must report all claims, even if the employee does not lose time. 2. Texas Form DWC-006 Supplemental Report of Injury- The employer must report within three (3) days from when the employee begins to lose time and also report within three (3) days when the employee returns to work. 3. Texas Form DWC-003 Employer s Wage Statement- Must be filed within thirty (30) days of the notice of injury, or within seven (7) days of a change in the wage information, or the case of a request by the Texas Division of the Workers Compensation. 4. 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-08-045 TGC (08/10)
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 Texas Form DWC-1 First Report of Injury (FROI)- and submit the form via one of the following: E-mail the completed form to wcreportaloss@twrgrp.com. This is the preferred method of reporting an injury. Fax to Tower Group Companies at 888-535-3407. Call the Tower Group Companies Claims office at 888-856-5522. By contacting your broker directly and providing the appropriate first report information. For injuries occurring after normal business hours, please call 888-856-5522. 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
DWC FORM-001 (Employer's First Report of Injury or Ilness) The employer is required to file an Employer's First Report of Injury or Ilness (DWe FORM-001 Rev. 10/051 with the injured worker's insurance carrier, and the injured claimant or the claimant's representative within 8 days after the employee's absence from work or receipt of notice of occupational disease. The Employer's First Report of Injury or Ilness provides information on the claimant, employer, insurance carrier and medical practitioner necessary to begin the claims process. Details of the claimant's employment and circumstances surrounding the injury or illness are also requested. Send the specified copies to your Workers' Compensation Insurance Carrier and the injured employee. *Employers - Do not send this form to the Texas Department of Insurance, Division of Workers' Compensation, unless the Division specifically requests a direct filing. Workers' Compensation Rule 120.2) owe FORM-001 Rev. 10/05 Page 1
INSTRUCTIONS FOR EMPLOYERS FIRST REPORT OF INJURY OR ILLNESS (DWC FORM-001) Type (or print in black ink) each item on this form. Failure to complete each item may delay the processing of the injury claim. Section 409.005, Texas Workers' Compensation Act, requires an Employer's First Report of Injury or Illness (DWC FORM-001 Rev. 10/05 to be filed with the Workers' Compensation Insurance Carrier not later than the eighth day after the receipt of notice of occupational disease, or the employee's first day of absence from work due to injury or death. A copy of this report must be sent to the employee or the employee's representative. For purposes of this section, a report is filed when personally delivered, or postmarked. Send the specified copies to your Workers' Compensation Insurance Carrier and the injured employee. *Employers - Do not send this form to the Texas Department of Insurance, Division of Workers' Compensation, unless the Division specifically requests a direct fiing. If a report has not been received by the carrier, the employer has the burden of proving that the report was filed within the required time frame. The employer has the burden of proving that good cause existed if the employer failed to fie the report on time. An employer who fails to file the report without good cause may be assessed an administrative penalty. An employer who fails to fie the report without good cause waives the right to reimbursement of voluntary benefits even if no administrative penalty is assessed. Once the employer has completed all information pertaining to the injury the employer should maintain the copy of this report to serve as the Employer's Record of Injury required by Section 409.006. Send the specified copies to your Workers' Compensation Insurance Carrier and the injured employee. *Employers - Do not send this form to the Texas Department of Insurance, Division of Workers' Compensation, unless the Division specifically requests a direct filing. The Division's Health and Safety will use data from this report for the Job Safety Information System established in Section 411.032 of the Texas Workers' Compensation Act. This report may not be considered admission or evidence against the employer or the insurance carrier in any proceeding before the Division or a court in which facts set out in the report are contradicted by the employer or insurance carrier. "SPECIAL INSTRUCTIONS FOR CERTAIN ITEMS" Items 2,7,8: Section 402.082, Texas Workers' Compensation Act requires the Division to maintain information as to the race, ethnicity and sex on every compensable injury. This information will be maintained for non-discriminatory statistical use. Item 4: If no home phone, please provide a phone number where the employee can be reached. Items 5,15,17, 26,29,30: Enter data in month, day, year format. Example: 08-13-54. Item 18: List nature of accident or exposure, e.g., fall from scaffold, contact with radiation, etc. If occupational disease, so state. Item 19: List specific body part, e.g., chin, right leg, forehead, left upper arm, etc. If more than one body part is affected, list each part. Item 20: Describe in detail (1) the events leading up to the injury/illness, (2) the actual injury, e.g., cut left forearm, broken right foot, etc., and (3) the reason(s) why accident/injury occurred. Use an additional sheet of paper if necessary. Item 22: State the exact work-site location of the injury, e.g., construction site, office area, storage area, etc. Item 24: List object, substance, or exposure that directly inflcted the injury or illness, e.g., floor, hammer, chemicals, etc. Items 32,33: Enter date in month-year format. Example: 02-56. Item 37: Enter the number of days or hours that make up a full work week for your employees. Item 45: Enter the 6-digit North American Industry Classification System (NAICS) Code of the employer. The primary code is the code which appears in block 5 of Form C-3, "Employer's Quarterly Report" to the Texas Workforce Commission. Item 46: For companies with a single NAICS code, the specific code is the same as the primary code. For companies with multiple NAICS codes, enter the code that identifies the specific business, activity, or work-site location the employee was working in at the time of the injury. This mayor may not be the same as the primary code. owe FORM-001 Rev. 10/05 Page 2
Send the specified copies to your Workers' Compensation Insurance Carrier and the injured employee. "Employers - Do not send this form to the Texas Department of Insurance, Division of Workers' Compensation, Unless the Division specifically requests a direct filling. CLAIM # I CARRIER'S CLAIM # EMPLOYERS FIRST REPORT OF INJURY OR ILLNESS 1. Name (Last, First, M.I.) 2. Sex 15. Date of Injury (m-d-y) 16. Time of Injury 17. Date Lost Time Began FD MO (m-d-y) - - am 0 pm 0 - - 3. Social Securily Number 5. Date of Birth (m-d-y) 18. Nature of Injury" 19. Part of Body Injured or Exposed" - - ( ) - - 14. Home Phone 6. Does the Employee Speak English? If No, Specify Language YES 0 NO 0 7. Race WhiteD 8. Ethnicity Hispanic 0 Black 0 Asian 0 Native American 0 Other 0 9. Mailing Address Street or P.O. Box 20. How and Why Injury/Illness Occurred" 21. Was employee 0 22. Worksite Location of Injury (stairs, dock, etc.)" doing his YES regular job? NO 0 23. Address Where Injury or Exposure Occurred Name of business if incident occurred on a business site eily State Zip eode eounly Street or P.O. Box eounly 10. Marital Status Married 0 Widowed 0 Separated 0 Sinnle 0 Divorced 0 11. Number of Dependent ehildren 12. Spouse's Name eily State Zip eode 24. eause of Injury(fall, tool, machine, etc.)" 13. Doctor's Name 25. List Witnesses 14. Doctor's Mailing Address (Street or P.O. Box) eily State Zip eode 26. Return to work 27. Did employee 28. Supervisor's 29. Date Reported date/or expected die? Name (m-d-y) (m-d-y) - - YESO NoD - - 30. Date of Hire (m-d-y) 131. Was YES employee 0 hired NO orrecruited 0 in Texas? Months 132. Length of Years Service in eurrent Position 34. Employee Payroll elassification eode Î 35. Occupation of Injured Worker I 33. Length Monthsof Service Years in Occupation I I 36. Rate of Pay at this Job 137. Full WorkWeek is: 138. Last Paycheck was: 139. Is employee an Owner, Partner, or eorporate Offcer? $_Hourly $_Weekly _ Hours _ Days $_ for _ Hours or _ Days YES 0 NO 0 1 40. Name and Title of Person eompleting Form 41. Name of Business 42. Business Mailing Address and Telephone Number 43. Business Location (If different from mailing address) Street or P.O. Box Telephone Number and Street ( ) eity State Zip eode eily State Zip eode 44. Federal Tax Identification Number eode:(6 digit) (6 digit) 145. Primary North American Industry elassification System I 46. Specific NAleS eode I 48. Workers' eompensation Insurance eompany 49. Policy Number 47. Texas eomptroller Taxpayer No. 50. Did you request accident prevention services in past 12 months? YES 0 NOD If yes, did you receive them? YESD NoD 51. Signature and Title (READ INSTRUeTIONS ON INSTRUCTION SHEET BEFORE SIGNING) X Date owe FORM-1 (Rev. 10/05) Page 3 1111111111 11111111111 II DIVISION OF WORKERS' eompensation
Part I EMPLOYER INFORMATION 1. Employer business name 3. Employer mailing address ~.:i!~" I~Y!" ".'-~~-''.' ::~-.. ~ t" '...,..~~,::~~~~/ SUPPLEMENTAL REPORT OF INJURY CLAIM' Carner # I 2. Employer phone # 4. Insurance carrier name 5. Does the employer have return to work (RTW) opportunities available based on the injured worker's current capabilities? yes DnoD If so, identify contact person and phone # 6. Has the insurance carrier provided RTW coordination services within the past 12 months? yes D 8. Has the insurance carrier provided accident prevention services in the past 12 months? yes D Date nod 7. Has the employer requested RTW training from DWC or the insurance carrier? yes D nod Date r.vd 9. Has the employer requested accident prevention services from the insurance carrier? yes D nod Part II REASON FOR FILING THIS REPORT (deadlines vary, see instructions) 10. a. The injured worker returned to work in either a full or limited capacity: File this report within 3 days. D b. The injured worker is earning more or less than the pre-injury wage because of the injury: File within 10 days. c. The injured worker returned, then later had additional lost time or reduced wages as a result of the injury: File within 3 days. The injured worker resigned or was terminated from employment: File within 10 days. D d. Part II INJURED WORKER INFORMATION 11. Injured worker name 12. SSN (last 4 digits) xxx-xx- 14. Injured worker mailing address and phone # 113. 001 15. First day of lost time or reduced 16. First day of additional lost time wages for this injury (mm/dd/yyyy) or reduced wages (mm/dd/yyy) 17, Has the injured worker experienced 8 days (cumulative) of lost time or reduced wages as a result of the injury? yes DnoD If yes, the date of the 8th day (mm/dd/yyy) 18. Date of most recent RTW 19. Has the injured worker resigned, been terminated or died? yes D nod I D Full duty, full pay I date of resignation date of termination date of death i D Limited duty, full pay I 19a. Reason for resignation/termination I D Limited duty, reduced pay I 19b. Was the injured worker on limited duty when terminated? yes DnoD 20. Hours the injured worker was working during the pay period of 21. Weekly/hourly earnings for the pay period of Indicated hours are: to hours per week to : $ weekly or $ Indicated wages are: D Increase from pre-injury D Increase from pre-injury wage D Same as pre-injury D Same a pre-injury wage D Decrease from pre-injury D Decrease from pre-injury wage The employer's insurance carrier and the injured worker in the timeframe as noted in Part II. This form to be fied with: 22. To the best of my knowledge the information provided in this report is accurate and may be relied upon for evaluation of eligibility for benefits. Submitted by: 0 Employer D Injured Worker (/f no longer working for the employer where injury occurred.) Signature and Title of person completing this form Date owe FORM-6 (Rev. 10/05) Page t 11111111111111111~I II DIVISION OF WORKERS' eompensation
DWCFORM-6 Supplemental Report of Injury DWC requires the reporting of all Return to Work and Post-Injury Change of Earnings. An injured worker is entitled to temporary income benefits if he/she has disability (defined as the inability to work, or the inability to earn wages equivalent to pre-injury wages, as a result of the injury) and has not reached maximum medical improvement (defined as having reached i 04 weeks from the eighth day of lost time or when a doctor certifies that no further recovery can be reasonably anticipated). The insurance carrier shall adjust the weekly amount of temporary income benefits paid to the injured worker to match the fluctuations in weekly earnings after the injury. To ensure the insurance carrier has accurate information to calculate benefits, the DWC FORM-6 is to be completed as applicable: By EMPLOYER The EMPLOYER means the employer for whom the injured worker was working when the injury occurred. If the employer is the current employer, then you are responsible to provide information to the workers' compensation insurance carier about:. The existence of earnings, and. The amount of any earnngs, or. Any offers of employment. Include CLAIM and insurance carrier numbers in right upper hand comer. Complete items 1-21, sign and date. The EMPLOYER must fie this form:. For a worker's injury/illness that occurs after January 1,1991 and required the previous fiing of a DWC FORM- i, Employer's First Report ofinjury; and. During the time the injured worker is entitled to temporary income benefits (TIBs); and. Unti the injured worker: ~ Reaches maximum medical improvement (MMI), or ~ Is no longer employed by the employer. By INJURED WORKER If you (the INJURED WORKER) are no longer employed by the employer where the injury/illness occurred, then you are responsible to provide information to the workers' compensation insurance carrier about: " The existence of earnings, and. The amount of any earnings, or. Any offers of employment. This form may be used to do so. Include CLAIM and insurance carrer numbers in right upper hand corner. Complete items 1-4, 10-2 i, sign and date. If you are employed by a new employer after the injury; and. You are receiving benefits, you must tell the insurance carrier if your wages change, regardless of whether your income went up or down; or. You are not receiving benefits, you must tell the insurance carrier if the injury causes you to miss work or lose income. his report must be fied in the following situations within the timeframes indicated:. 3 days after the injured worker begins to lose time from work as a result of the injury, iflost time did not occur immediately following the injury;. 3 days after the injured worker returns to work;. 3 days, when the injured worker returned to work, then later has additional day(s) of lost time as a result of the injury;. 10 days after the end of each pay period in which the injured worker has a change in earnings as a result of the injury;. 10 days after the injured worker resigns or is terminated. While most of the sections on this form are self-explanatory, please note that the pay periods requested in sections 20 & 21 may be different depending on the situation for which the form is being fied:. If the report is indicating lost time from work or the end of employment, the pay period shall be the most recent pay period prior to the lost time.. If the report is indicating return to work or a change in earnings, the pay period shall be the pay period the injured worker is beginning. This form is to be fied by first class mail or personal delivery with:. The insurance carrier, and. The injured worker. This report is considered filed when personally delivered or postmarked. This form is to be fied by first class mail or personal delivery with:. The insurance carrier. This report is considered filed when personally delivered or postmarked. If you return to work for the same employer or a different employer, your temporary income benefits from the insurance carrier must be adjusted. Failure to comply with these fiing requirements, without good cause, is a Class D administrative violation, subject to a penalty not to exceed $500. Failure to report earned wages and/or offers of employment to the insurance carrier who is paying benefits to you is a crime that may result in fines and/or imprisonment. TLC 409.005 and Rules 120.3 and 129.4 provide the requirements regarding use of this report. The complete rule text is available on the DWC website at: www.tdi.state.tx.us owe FORM-6 (Rev. 10/05) Page 2 1~I1111111111111111 II DIVISION OF WORKERS' eompensation
Send to workers' compensation carrier: D Initial (Name and fax number of carrier) DAmended CARRIER'S CLAIM # i CLAIM # EMPLOYER'S WAGE STATEMENT (Owe Form-003) The Texas Workers' Compensation Act and Workers' Compensation rules require an employer to provide an Employer's Wage Statement to its workers' compensation insurance carrier (carrier) and the claimant or the claimant's representative, if any. The purpose of the form is to provide the employee's wage information to the carrier for calculating the employee's Average Weekly Wage (AWW) to establish benefis due to the employee or a beneficiary. The AWW is based on the wages the employee earned in the 13 weeks immediately preceding the date of injury (or the wage a similar employee earned if the employee did not work the full 13-week period). "Wages" include all forms of remuneration payable to an employee for personal services, including fringe benefits. To simplify filing, employers may file wages in a monthly, biweekly, or weekly manner as discussed below. NOTE - An employer who fails without good cause to timely file a complete wage statement as required by the Texas Workers' Compensation Act, Texas Labor Code, Section 408.063(c) and Worker's Compensation Rule 120.4 may be assessed an administrative penalty. EMPLOYEE AND EMPLOYER INFORMATION Employee's Name (Last, First, M.I.): The employer shall timely file a complete wage statement in the form and manner prescribed by the Division. (1) The wage statement shall be filed ("filed" means received) with the carrier, the claimant, and the claimant's representative (if any) within 30 days of the earliest of: (A) the employee's eighth day of disability; (B) the date the employer is notified that the employee is entitled to income benefits; (C) the date of the employee's death as a result of a compensable injury. (2) The wage statement shall also be filed with the Division within seven days of receiving a request from the Division (Only When Requested). (3) A subsequent wage statement shall be filed with the carrier, employee, and the employee's representative (if any) within seven days if any information contained on the previous wage statement changes (such as if the employer discontinues providing a nonpecuniary wage that was initially continued after the date of injury). All applicable DWC rules can be found at www.tdlstate.tx.us Employer's Business Name: Employee's Mailing Address (Street or P.O. Box): Employer's Mailing Address (Street or P.O. Box): City: State: zip Code: City: State: zip Code: Social Security Number: Federal Tax J.D. Number: XXX-XX- Date of Hire: Date of Injury: Name and Phone # of Person Providing Wage Information: o As of today's date, the employee is not back at work. OR o The employee returned to work on and is working: i HEREBY CERTIFY THAT this wage statement is complete, accurate, and o without restriction. OR complies with the Texas Workers' Compensation Act and applicable rules, and the listed wages include all pecuniary and nonpecuniary wages paid for o with restrictions and is earning wages of $ per week/month (circle one). (earned in) the 13 weeks prior to the date of injury (as described on page 2) and I understand that making a misrepresentation about a workers' NOTE - Rule 120.3 requires the employer file the Supplemental Report of compensation claim is a crime that can result in fines and/or imprisonment. Injury (DWC FORM-6) to report changes in Work Status and Post-Injury Earnings. Signature: Date: EMPLOYMENT STATUS AT TIME OF INJURY (Check All That Apply) i: Full-time: employee who regularly works at least 30 hours per week and whose schedule is comparable to other employees of the company and/or other employees in the same business or vicinity who are considered full-time. D Seasonal: employee who as regular course of conduct engages in seasonal or cyclical employment that mayor may not be agricultural in nature and that does not continue throughout the year. SAME OR SIMILAR EMPLOYEE? The wage information on this form is for: o The Injured Employee OR D A Similar Employee (NOTE - If requested by the Division, the employer shall identify the similar employee whose wages were provided.) i: Part-time: Regular Course of Conduct: employee whose work history for the 12-month period preceding the injury shows the person only worked part-time during that period. D Part-time: Not Regular Course of Conduct: employee whose work history for the 12-month period preceding the injury shows part-time and full time work during that period. (J Apprentice: employee who is learning a skilled trade or art by practical experience under the direction of a skilled crafts person or artisan. o Minor: employee less than 18 years of age and not emancipated by marriage or judicial action who is also an apprentice, trainee or student. i: Student: employee enrolled in a course of study in high school, college or other institute of higher education or technical training. D Trainee: employee undergoing systematic instruction and practice in some art, trade or profession with a view towards proficiency in it. If the employee was not employed for 13 continuous weeks before the date of injury, report the wages of an employee who has training, experience, skills & wages comparable to the injured employee AND who performs services/tasks comparable in nature and in number of hours. If no similar employee exists, report the limited available wages earned by the injured employee prior to the injury. NOTE TO INJURED EMPLOYEE - If you were injured on or after 7/1/02, and had employment with more than one employer on the date of injury, you can provide your insurance carrier with wage information from your other employment for the carrier to include in your AWW and this may affect your benefits. Contact our carrier for additional information or call the Division at 800) 252-7031. You can also read rule 122.5 at ww.tdi.state.tx.us/wc/rules/. owe FORM-003 Rev. 10/05 Page I
WAGE INFORMATION INSTRUCTIONS PECUNIARY WAGE INFORMATION Employee Name: Social Security #: Date of Injury: - The employer shall report all wages earned in the 13 weeks immediately preceding the date of injury. If the employee is paid on a monthly or semi-monthly basis, the employer may provide wages for the 3 months preceding the date of injury. Monthly wages may also be converted to weekly wages by dividing the gross monthly amount by 4.34821. If the employee is paid on a biweekly basis, the employer may provide the wages for the 14 weeks preceding the date of injury. When setting the periods to report, the employer may adjust the reporting period backward slightly (up to six days) to line up the reporting timeframes with the employer's natural pay cycle. However, the employer shall not report wages earned on or after the date of injury, - If reporting weekly earnings, use all 13 Period Columns below. If reporting 3 months of earnings, either convert the wages to weekly earnings or use the first 3 Period Columns. If reporting 14 weeks of biweekly earnings, use the first 7 Period Columns. In all cases, indicate the dates that each period covers. PERIOD # (Week #, Month #, or Bi-Week # FROM DATE: 2 3 Pecuniary Wages include all wages that are paid to the employee in the form of money. These include, but are not limited to: houriy, weekly, biweekly, monthly, etc. wages; salary; tlps!gratuities; piecework compensation; monetary allowances; bonuses; and commissions. Earnings are reported in the periods they are earned, NOT when they are paid and some (such as bonuses and commissions) need to be prorated. Pecuniary wages don't include payments made by an employer to reimburse the empioyee for the use of the empioyee's equipment or for paying helpers or to reimburse for travel expenses. Consider as earnings amounts from paid holida s and an vacation, ersonal or sick leave an em 10 ee used but not the market value of leave time earned but not used. 4 5 6 7 8 9 10 11 12 13 TO DATE: # HOURS WORKED: TOTALS GROSS WAGES EARNED: NONPECUNIARY WAGE INFORMATION Nonpecuniary Employer Wage Type Provided Prior To Injury? Health Insurance Nonpecuniary Wages include all wages paid to the employee in a form other than money. These include, but are not limited to, the benefits listed below but do not include monetary allowances or stipends paid to allow the employee to purchase the benefits. Specify Value Or Amount Earned in Each Reported Period For Each Benefit Provided Prior To Injury Will Employer Date Benefit (Use the same periods as used above) Continue To Suspended Provide? (if suspended) YES NO 2 3 4 5 6 7 8 9 10 11 12 13 YES NO Laundry! Cleaning Clothing! Uniforms Lodging! Housing! Food! Meals Vehicle! Fuel Other NOTE: With few exceptions, you are entitled on request to be informed about the information that TDI-DWC collects about you, Under 552.021 and 552.023 of the Government Code, you are entitled to :::~~:M:::::~~:::~~'IiOO. Uod" 559.004 ofth, G""om,ot Cod, YOllltll to r r-nri 'oinrrr m Ih" ','ow"oci Fo, mo," lofmm,lioo, "" th, '0'" ::~:WC
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
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 1-800-243-2336 x 4680. 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 e-mail. 2. Internet Access: For the standard national workers compensation network go to www.talispoint.com/cvty/twrgrp 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.
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 312-277-1600. 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.
Re: Important Information about your Workers Compensation Prescriptions This letter is provided to inform you that your employer s workers compensation, Tower Group Companies, has selected PMSI as its workers compensation pharmacy partner.with PMSI, you can choose to pick-up your medications for your work-related injury at a nearby pharmacy through a program known as Tmesys, or have them delivered to your home through the mail. Within the next few weeks, you will receive a new workers compensation pharmacy card in the mail. You should give the Tmesys card to the pharmacist at a participating pharmacy of your choice with your next refill or new prescription for your work-related injury. If you do not receive your new pharmacy card within two weeks, please call Tmesys at 1.866.599.5426 and we will be happy to assist you or send another card. If you are interested in finding out about how to receive your prescriptions through the mail, please call 1.800.304.1764. To help you transition to the new pharmacy program, we have provided answers to some frequently asked questions: Q: How do I know if my pharmacy participates with the new program? A: You can find out if your normal preferred pharmacy is part of the Tmesys network by referring to the Pharmacy Center on our website, www.pmsionline.com/pharmacy-center. Click on Pharmacy Locator and select how you would like to search for a nearby pharmacy. You may also call the helpdesk at 1.866.599.5426 to find a network pharmacy near you. Q: How does this affect my workers compensation claim? A: Using PMSI s program for your workers compensation medications will enable you to continue to receive your prescriptions for your work-related injury. You may choose to visit your local pharmacy, as long as the pharmacy is one of the more than 60,000 pharmacies in the Tmesys network, or you can have your prescriptions delivered to your home through our convenient mail order program. Q: Who do I call with questions about the program? A: PMSI has representatives available to help you with any questions that you may have about the pharmacy program. Please call our help desk at 1.866.599.5426 to speak to a representative. If you have any questions about your workers compensation claim, we will help you reach your claims adjuster for assistance. We look forward to serving you and meeting your workers compensation medication needs. Sincerely, PMSI Necesitas ayuda en español? Llame al 1.866.599.5426
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 1.866.599.5426 Necesitas ayuda en español? Llame al 1.866.599.5426 Prescription Card CARRIER / TPA INJURED WORKER NAME SOCIAL SECURITY NUMBER EMPLOYER DATE OF INJURY Attention Pharmacists: Call 800.964.2531 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 800.964.2531 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 866.599.5426. NDC Envoy RxBin 004261 or 002538 RxPCN CAL or Envoy Acct. # Pharmacist: 1. Call the Tmesys Pharmacy Help Desk at 800.964.2531. 2. 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: 866.599.5426 Use our pharmacy locator online: www.tmesys.com. 2011 PMSI, Inc. All rights reserved. C1257-1011-02..
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 1.866.599.5426 Need help in English? Call 1.866.599.5426 Prescription Card PORTADORA NOMBRE DEL TRABAJADOR LESIONADO NUMERO DE SEGURO SOCIAL EMPLEADOR FECHA DE LA LESIÓN Attention Pharmacists: Call 800.964.2531 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 800.964.2531 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 866.599.5426. NDC Envoy RxBin 004261 or 002538 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 800.964.2531. 2. 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: 866.599.5426. Utilice nuestro localizador de farmacias en linea: www.tmesys.com. 2011 PMSI, Inc. Todos los derechos reservados. C1257-1011-03..
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