Claims Kit - ProSight Specialty Insurance

Transcripción

WORKERS’ COMPENSATION
Claims Kit
Dear Customer,
Thank you for choosing ProSight Specialty Insurance as your Workers’ Compensation
Insurance carrier. We pride ourselves on providing excellent service and will do our
very best to meet your Workers Compensation Claims needs. ProSight Specialty Insurance writes our Workers’ Compensation policies through our
New York Marine and General Insurance Company underwriting company, which is
the name you will see listed on your policy.
ProSight has partnered with two leading Workers’ Compensation claims service
providers, LWP Claims Solutions and Gallagher Bassett Services, to assist us in the
administration of claims. To determine whether your claims will be handled by ProSight
or one of our partners, please refer to the map included with this packet.
Please make sure to include your Policy Number on all correspondence.
For your convenience, the following documents can be found inside your claims kit:
•
•
•
•
•
•
•
Instructions on how to report a claim
Claim Handling Map
List of Claim office locations, mailing addresses, and claim contacts
How to locate a Physician/Facility
Pharmacy cards
Links to your state’s Workers’ Compensation forms and Web Pages
Blank forms to use when reporting a claim (California only)
Please do not hesitate to contact us should you have any questions or concerns.
Workers’ Compensation Claims Department
ProSight Specialty Insurance
412 Mt. Kemble Avenue
Morristown, NJ 07960
[email protected]
Phone: 800-774-2755
Fax: 855-657-3534
Need to Report a Claim?
By e-mail:
[email protected]
By phone:
(800)-774-2755
Press ‘1’ to report a claim
(Available anytime- days, nights & weekends)
Press ‘2’ to inquire about a claim
(Available 8:00am to 5:00pm EST)
By fax:
(800)-326-2864
By Mail:
ProSight Specialty Insurance Claims Department
Suite 300C
Additional Instructions:
• If you are a Workers’ Compensation Policyholder you are eligible to
participate in online reporting of your Workers’ Compensation Claims.
(Registration is required for online reporting, see instructions below)
Online:
www.netclaim.net
• To register for online reporting, please e-mail your request to
[email protected] with your full name, company name, phone
number, fax number, policy number and be sure to mention that you are a
ProSight customer.
• If you have any supporting documents (reports, bills, etc.) associated with
a newly reported claim, please wait for the examiner’s contact information.
Do not send these documents to the call center.
EXPERIENCED PROFESSIONALS.
INSIGHTFUL SOLUTIONS.SM
Workers’ Compensation Claim Handling
Washington
Montana
New Hampshire
Vermont
North Dakota
Maine
Minnesota
Oregon
South Dakota
Idaho
Nebraska
Pennsylvania
Iowa
Illinois
Utah
Colorado
California
New York
Kansas
Indiana
Ohio
Oklahoma
New Mexico
New Jersey
Delaware
Maryland
West
VirginiaVirginia
Missouri
Kentucky
Arizona
Rhode
Island
Connecticut
Michigan
Wyoming
Nevada
Massachusetts
Wisconsin
North
Carolina
Tennessee
South
Carolina
Arkansas
Mississippi
Alabama
Georgia
Texas
Louisiana
Alaska
Hawaii
Florida
Gallagher Bassett Services
LWP Claims Solutions
Monopolistic
Claims Handling Offices | ProSight Specialty Insurance
Mailing
Workers’ Compensation Claims Department
[email protected]
Phone: 800-774-2755
Fax: 855-657-3534
Contacts
WC Claims Manager: Melissa Kovacsy
[email protected]
Lost Time Adjuster: Patrick Gano
[email protected]
Medical Only Adjuster: Melinda Bullock
[email protected]
Alabama
Arkansas
California
Colorado
Connecticut
Delaware
DC
Florida
Georgia
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maryland
Massachusetts
Michigan
Minnesota
Missippi
Missouri
Nebraska
New Hampshire
New Jersey
New York
North Carolina
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Utah
Vermont
Virginia
West Virginia
Wisconsin
Claims Handling Offices | Alaska
Mailing
Wilton Adjustment Service, Inc. – 425
625 E. 34th Avenue, Suite 400
Anchorage, AK 99503
Phone: 907-276-3311
Fax: 907-276-7877
Contacts
Branch Manager: Joanne Pride, x 3412
[email protected]
Adjuster: McKenna Wentworth, x 3452
[email protected]
Medical Only: Shea Loescher, x 3317
[email protected]
Alaska
Claims Handling Offices | Arizona
Mailing
Gallagher Bassett Services- 007 (Phoenix)
PO Box 10849
Scottsdale, Arizona 85271
Phone: 480-586-9500
Fax: 480-443-8416
Toll Free: 800-231-3759
Contacts
Branch Manager: Bruce Martin
[email protected]
Arizona
Claims Handling Offices | California
Mailing
LWP Claims Solutions, Inc.
P.O. Box 349016
Sacramento, CA 95834-9016
Toll Free: 1-800-565-5694
Phone: 916-609-3600
Fax: 408-725-0395
Contacts
LaVonne Cianci
Claims Supervisor
California
Claims Handling Offices | Hawaii
Mailing
Gallagher Bassett Services -162
900 Fort Street, Suite 420
Honolulu, HI 96813-4511
Phone: 808-532-7362
Fax: 808-545-5967
Toll Free: 877-492-9645
Contacts
Nadine Kurihara-Nakasu, Branch Manager
[email protected]
Hawaii
Claims Handling Offices | Idaho
Mailing
Gallagher Bassett Services – 193
720 East Park Blvd., Suite 125
Boise, ID 83712
Phone: 208/345-8090
Fax: 208/345-3996
Toll Free: 866/217-1192
Contacts
Regina Pearson, Branch Manager
[email protected]
Idaho
Claims Handling Offices | Maine
Mailing
Gallagher Bassett Services - 120 (Boston)
100 Grandview Road, Suite 406
Braintree, MA 02184
Phone: 781-849-9090
Fax: 781-849-8558
Toll Free: 800-307-5256
Contacts
Lauri Lancaster, Branch Manager
[email protected]
Maine
Claims Handling Offices | Montana
Mailing
Gallagher Bassett – 080 (Missoula)
2501 Catlin Street, Suite 200
Missoula, MT 59801
Phone: 855-335-7892
Fax: 406-721-2735
Contacts
Regina Pearson
208-515-3835
[email protected]
Montana
Claims Handling Offices | Nevada
Mailing
Gallagher Bassett Services – 156
P.O. Box 70030
Las Vegas, NV 89170
Phone: 702-789-4500
Toll Free: 866-889-4755
Fax: 866-823-4130
Contacts
Charles Rostad, Branch Manager
[email protected]
(UPS, Federal Express, etc)
2110 E. Flamingo Road, Suite 314
Las Vegas, NV 89119
Nevada
Claims Handling Offices | New Mexico
Mailing
Gallagher Bassett Services - 046
2424 Louisiana NE, Suite 220
Albuquerque, NM 87110
Phone: 505-837-2180
Fax: 505-837-2187
Toll Free: 866-859-2180
Contacts
Regina Pearson, Branch Manager
[email protected]
New Mexico
Claims Handling Offices | Oklahoma
Mailing
Gallagher Bassett Services - 132
6303 Waterford Blvd., Suite 120
Oklahoma City, OK 73118
Phone: 405/843-7244
Fax: 405/843-8658
Toll Free: 800/943-7244
Contacts
Stacy Goble, Branch Manager
[email protected]
Oklahoma
Claims Handling Offices | Oregon
Mailing
Gallagher Bassett Services – 155 (Portland)
4550 Kruse Way, Suite 155
Lake Oswego, OR 97035
Phone: 503-675-6575
Fax: 503-675-6574
Toll Free: 877-800-3059
Contacts
Eric Sorem, Branch Manager
[email protected]
Oregon
Claims Handling Offices | Texas
Mailing
Gallagher Bassett Services - 025 (Dallas)
6404 International Parkway, Suite 2300
Plano, Texas 75093
Phone: 972-931-6277
Fax: 972-931-6256
Toll Free: 800-382-0166
Contacts
Terry Tarter, Branch Manager
[email protected]
Texas
Navigating the Coventry Medical
Provider Directory Website
Use this search tool to locate Medical Providers
ONLY If your claims are administered by ProSight
•
Go to http://coventrywcs.com/client-tools/index.htm
•
Select the radial button for First Health Portal Login/Coventry login (GeoAcess Channeling Tools)
•
In the client ID field , type in “Sols”
•
A new page will appear, click on the link “Channeling Tools”
•
The next page will give you four options to choose from:
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Address Search: This option is a radius search from a centralized address.
•
Name Search: Allows the user to look up a certain provider in the database by name or phone.
•
Region Search: This option allows the user to search in a specific region such as city, county, zip
code, etc.
•
Quick Search: A search using a limited number of specialties for providers who provide initial
treatment to a maximum radius of 35 miles around an address. Creates output to a custom
Worksite Poster or Directory.
•
Worksite Posters: This option allows the user to make a Worksite Poster with the closest network
providers while following all jurisdictional regulations and guidelines.
ADDRESS SEARCH
Begin by selecting the Network you wish to search. Enter your address. You must enter at least a valid ZIP
Code or a City/State combination. At the bottom of the page you may choose: Provider Types, Specialties
and/or distance. Once you click on “find providers” your results will be displayed.
NAME SEARCH
Use the Name Search tab if you already know a Provider’s name, group affiliation or phone
REGION SEARCH
Use this feature if you are searching for a provider in a specific area.
QUICK SEARCH
Use this tab if you are searching for ONLY one of the following: Family Practice, Internal Medicine,
Occupational Medicine, Emergency Medicine and Occupational Medical Clinics within 35 miles of a specific
address.
WORKSITE POSTER (WSP)
This page is used to create Worksite Posters or batches of Posters. For your convenience, you can upload
your Locations and create your posters!
Navigating LWP’s Kaiser Signature
Medical Provider Lookup Website
For Policyholders enrolled in the Kaiser Network, use this
search tool to locate In-Network Medical Providers in
California Only, excluding all other states
•
Go to www.lwpkaisersignaturempn.com
•
•
Select by Distance: This option is a radius search from a centralized address.
•
Select by Name: Allows the user to look up a certain provider in the database by name.
•
Regional Listing: This option allows the user to search in a specific region such as city, county, zip
code, etc.
•
Statewide Directory: Enter your e-mail address to recive a statewide directoy of providers.
•
Panel Cards: This option allows the user to make a Panel Card once they have initiated a search
for providers by using on of the methods listed above.
SELECT BY DISTANCE
SELECT BY NAME
Use the Name Search tab if you already know a Provider’s name or group affiliation.
REGIONAL LISTING
STATEWIDE DIRECTORY
address.
PANEL CARDS
This page is used to create Panel Cards or batches of Panel Cards. For your convenience, you can choose
providers from one of the three search methods and create a Panel Card for the providers closest to each of
your locations.
Navigating the Coventry Primary
Medical Provider Directory Website
Use this search tool to locate In-Network Medical Providers
in California Only, excluding all other states
•
•
Go to http://www.talispoint.com/cvty/mpnpri
•
•
•
code, etc.
•
•
ADDRESS SEARCH
NAME SEARCH
REGION SEARCH
QUICK SEARCH
address.
Navigating the Coventry Medical
Provider Directory Website
Use this search tool to locate Medical Providers
ONLY If your claims are administered by Gallagher Bassett
•
Go to www.firsthealth.com/welcome
•
Enter Login ID: GBMCS
•
A new page will appear, click on the link “Channeling Tools”
•
•
•
•
code, etc.
•
•
ADDRESS SEARCH
NAME SEARCH
REGION SEARCH
QUICK SEARCH
address.
Temporary Prescription Services ID
For Claims Administered by ProSight
Attached you will find a prescription form (also called a temporary pharmacy
card) that must be given to each and every employee when there is an on the
job injury. The employee needs to go to one of the pharmacies listed on the
bottom of the form to get their Workers Compensation prescription(s) filled.
They should follow the steps on the top of the form under the heading
“Instructions to the Injured Worker.”
It is a good idea to distribute these forms to your Supervisors, Team Leaders,
and your Human Resources department so they are familiar with the form.
Chances are they will receive the notices of injury and will likely be responsible
for handing the form to the injured employee. They need to follow the steps
under the heading “Instructions for the Company.”
Progressive Medical, Inc. has been chosen to manage your workers' compensation prescription
plan on behalf of your insurer or employer.
Below is your First Fill® card that allows you to fill your initial workers’ compensation
prescriptions at your local pharmacy at no extra cost to you.
Questions?
888.908.6337
Instructions for the Company
x Fill in the ID/Auth# per the First Fill card below along with the name, date of birth and
gender.
x Instruct the injured worker to take the First Fill card and their prescription to the
pharmacy.
x Report the claim to the appropriate insurance company/TPA.
Note: If additional medications are required, the claims professional should contact Progressive Medical
to use our Retail Drug Card program. If additional First Fill cards are needed or if you have any questions
about the use of this program, please contact Progressive Medical at 888.908.MEDS and ask for the
Pharmacy Services Coordinator.
Questions?
Instructions for the Injured Worker
888.908.6337
x Report your injury to the appropriate staff.
x Below is a First Fill card that will allow you to obtain the “initial” prescriptions needed
upon injury with no out-of-pocket expense.
x A sample list of participating pharmacy chains that accept this First Fill card is on the
back of this sheet.
x Present your First Fill card and your prescription to the pharmacist.
x This card is for a one time use to receive your medications per your company benefits.
Use of this card is only for your workers’ compensation injury for which this claim was
made.
x If you have any questions, call Progressive Medical toll-free at 888.908.MEDS. Our
Client Services Specialists are available 24-hours a day to take care of your needs.
PLEASE NOTE: IF YOUR WORKERS’ COMPENSATION CLAIM IS ACCEPTED, YOU WILL RECEIVE
A RETAIL DRUG CARD IN THE MAIL. PRESENT THAT CARD WHEN FILLING OTHER INJURYRELATED PRESCRIPTIONS.
FIRST FILL® CARD
BIN#:
888.908.MEDS
Restat 600471
PCN:
7777
You may contact Progressive Medical for issues
with your card, prior authorization or claim
rejections, by calling 888.908.6337.
Company Name: Prosight Specialty Insurance
Group/Plan#:
J013
Person Code:
00 (zero, zero)
Pharmacist: If you experience any problems,
please call 888.908.6337.
ID/Auth#:
SSN (9 digits, no dashes) Date (6 digits, no dashes)
E.g. if the SSN is 000-00-0000 and today’s date is May 21,
2007, the ID/Auth# is 000000000052107.
Injured Worker’s Name:
Date of Birth:
250 Progressive Way Westerville, OH 43082
Gender:
800.777.3574
Disclaimer: It is important to note the issue will be
determined by the claims department and the confirmation
of this treatment/ service request is in no way intended as
an endorsement of the treatment/service request, nor is it
intended to interfere with the provider from his or her duty
to adhere to any applicable practice standards.
[email protected]
www.progressive-medical.com
Cuando una persona lesionada necesita medicamentos de inmediato, la opción con la tarjeta
First Fill (Surtir primero) le permite autorizar estas recetas y ayudarle a recuperarse.
¿Preguntas?
888.908.6337
Instrucciones para la compañía
x Anote el número de identificación/autorización en la tarjeta First Fill al verso junto con el
nombre, la fecha de nacimiento y el sexo.
x Indique al trabajador lesionado que lleve la tarjeta First Fill y su receta a la farmacia.
x Reporte la reclamación a la aseguradora/TPA apropiada.
Nota: Si se requiere recibir medicamentos adicionales continuamente, el profesional de reclamaciones
debe ponerse en contacto con Progressive Medical para utilizar nuestro programa de Tarjeta de
Medicamentos al por Menor. Si se necesitan tarjetas First Fill adicionales, o si tiene alguna pregunta
sobre cómo usar este programa, llame a Progressive Medical al 888.908.MEDS y pida hablar con el
Coordinador de Farmaceuta.
¿Preguntas?
Instrucciones para el trabajador lesionado:
888.908.6337
x Reporte la lesión al personal apropiado.
x En la parte inferior de este formulario aparece una tarjeta First Fill que le permitirá
obtener los medicamentos “iniciales” necesarios para la lesión sin costo de su propio
bolsillo.
x A continuación se encuentra una lista de muestra de las cadenas de farmacias
participantes que aceptan esta tarjeta First Fill.
x Presente su tarjeta First Fill y su receta al farmacéutico.
x Esta tarjeta sólo se puede usar una vez para recibir sus medicamentos de acuerdo con
los beneficios de su compañía. Utilícela únicamente para la lesión que cubre el seguro
de compensación a los trabajadores para la cual se presente el reclamo.
x Si tiene alguna pregunta, llame gratis a Progressive Medical al 888.908.MEDS.
Nuestros Especialistas de Servicios al Cliente están disponibles las 24 horas del día.
NOTA: SI SE ACEPTA SU RECLAMO DE SEGURO DE COMPENSACIÓN A LOS TRABAJADORES,
RECIBIRÁ POR CORREO UNA TARJETA DE FARMACIA AL POR MENOR. PRESENTE ESA
TARJETA AL SURTIR RECETAS SUBSECUENTES RELACIONADAS CON EL TRABAJO.
Sample Listing of Participating Pharmacies
The below is a sampling of pharmacies that honor our program:
Albertsons
Safeway
Meijer Pharmacy
Walgreens
K-Mart
Tops Markets
Longs Drug Stores
Giant Eagle Pharmacy
Publix Pharmacy
Rite Aid Pharmacy
Fred Meyer
Medicine Shoppe
Costco
Winn Dixie Pharmacy
CVS Pharmacy
Discount Drug Mart
Target Pharmacy
Wal-Mart Pharmacy
For additional pharmacies within your area call Progressive Medical’s Client Services
department at 888.908.6337 or visit our website at www.progressive-medical.com. Go to
Workers’ Compensation, Tools and Resources, Pharmacy Look-Up and enter your city, state or
zip code and click on “Submit”. You will see a listing of pharmacies in your area.
250 Progressive Way Westerville, OH 43082
800.777.3574
[email protected]
www.progressive-medical.com
California Only
job injury. The employee needs to go to one of the pharmacies listed on the
bottom of the form to get their Workers Compensation prescription(s) filled.
They should follow the steps on the top of the form under the heading
“Injured Party.”
for handing the form to the injured employee. They need to follow the steps
under the heading “Instructions for Company.”
Prescription Authorization
LWP Claims Solutions, Inc/Workers’ Compensation
LWP Claims Solutions, Inc. and Progressive Medical, Inc. have joined together to provide your eligible injured parties with a First Fill®
prescription medication card program. At the bottom of this form is a First Fill® medication card that enables injured parties to obtain the
“initial” prescription(s) needed upon injury, with little to no out–of–pocket expense.
Instructions for Company to use this First Fill® card:
x
Injury occurs and a report of injury is made to the appropriate personnel.
x
Fill in the eligible injured party’s name, social security number, employer, date of birth, gender and date of injury on the form
below.
x
After explaining the instructions for this card, please give the eligible injured party this document.
x
Instruct the eligible injured party to take the First Fill® card and their prescription to the pharmacy.
x
Report the claim to the appropriate insurance company/TPA.
x
The pharmacist fills the medication; the bill is processed and sent to Progressive Medical.
x
The First Fill® card is available for a one time use.
**Please note: If additional, ongoing medication is required, the claims handler should contact Progressive Medical to utilize our Retail Medication Card
Program.
Injured Party:
At the bottom of this form is a First Fill® Card that will enable you to obtain the “initial” prescription(s) needed upon injury with little to
no out-of-pocket expense. A sample list of “Participating Pharmacy Chains” that accept this First Fill® card is also included below.
This card is for a one time use to receive your medication(s) per your employer/insurance company.
Use of this card is restricted to your allowed condition.
To receive this benefit, present this card to a participating pharmacy along with your prescription from your Doctor.
If you have any questions, call Progressive Medical, toll free, at 1-888-909-MEDS. Out Client Service Specialists are available 24-hours a
day to take care of your needs.
**Please note: If your claim is accepted, you will receive a retail pharmacy card in the mail. Present that card when filling subsequent related
prescriptions.
Participating Pharmacies:
Brooks Pharmacy
Harris Teeter Pharmacy
Rite Aid Pharmacy
CVS Pharmacy
Kmart Pharmacy
Walgreens Pharmacy
Eckerd Pharmacy
Kroger Pharmacy
Wal-Mart Pharmacy
Longs Drugs
Winn Dixie Pharmacy
For additional pharmacies in your area, please visit www.progressive-medical.com. Select the Total Pharmacy Management option, then
select the Pharmacy Locator. Enter your City, State, or Zip Code and click the locator button. You will see a listing of all participating
pharmacies within your specified area.
Instructions for Pharmacist:
LWP Claims Solutions, Inc. participates with Progressive Medical in an online pharmacy benefit program. This form is valid for Workers’
Compensation prescriptions only.
Please transmit all claims online to Progressive Medical:
Bin #: 600471
Process Control #: 7777
Group #: A290
__________
For all other questions call toll-free the Progressive Medical Pharmacy Help Desk at 1-888-908-6337.
Injured Worker Information:
Name of Eligible Injured Party:
________________________________________________
ID/Auth # ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____
(Combination of Social Security Number – 9 digits, no dashes, and today’s date/date of injury – 6 digits, no dashes; ie., Social Security
Number of 123-45-6789 and Date of Injury July 17, 2006 would be the ID# 123456789071706 )
Date of Birth: __________________
Gender: ________
Employer: ______________________________________________
12 27 07
First Fill
Autorización de medicamentos recetados
LWP Claims Solutions, Inc/Compensación del seguro obrero
LWP Claims Solutions, Inc. y Progressive Medical, Inc. se han unido para proporcionar a las personas lesionadas que califican un
programa de tarjeta de medicamentos recetados “First Fill®”. A pie de página figura una tarjeta de medicamentos First Fill® que permite a
las personas lesionadas obtener la receta o recetas “iniciales” necesarias después de sufrir una lesión sin gastos de su propio bolsillo o con
muy pocos gastos.
Instrucciones para que la Compañía use esta tarjeta First Fill®:
x
Se produce una lesión y se notifica dicha lesión al miembro del personal correspondiente.
x
Se llena el nombre de la persona lesionada que califica, su número de seguro social, empleador, fecha de nacimiento, sexo y
fecha de la lesión.
x
Después de explicar las instrucciones referentes a esta tarjeta, se da este documento a la persona lesionada que califica.
x
Se indica a la persona lesionada que califica que lleve la tarjeta First Fill® y la receta a la farmacia.
x
Se notifica la reclamación a la compañía de seguros o TPA (administrador de terceros) correspondiente.
x
El farmacéutico surte la receta, se procesa la factura y se envía a Progressive Medical.
x
La tarjeta First Fill® está disponible para usarse sólo una vez.
**Nota: Si se requieren más medicamentos para continuar el tratamiento, el encargado de las reclamaciones debe comunicarse con Progressive
Medical para utilizar nuestro Programa de Tarjeta para Medicamentos al Por Menor.
Persona lesionada:
A pie de página figura una tarjeta First Fill® que le permitirá obtener la receta o recetas “iniciales” necesarias después de sufrir una lesión
sin gastos de su propio bolsillo o con muy pocos gastos. Se incluye más adelante una lista de las “Cadenas farmacéuticas participantes” que
aceptan esta tarjeta First Fill®.
Esta tarjeta es para usarse una vez con el fin de recibir el medicamento o medicamentos según su empleador/compañía de seguros
El uso de esta tarjeta se limita a la lesión/problema médico permitido.
Para recibir este beneficio, presente esta tarjeta en una farmacia participante junto con la receta de su médico.
Si tiene alguna pregunta, llame gratis a Progressive Medical al 1-888-909-MEDS. Nuestros especialistas en servicio al cliente se
encuentran a su disposición las 24 horas del día para atender sus necesidades.
**Nota: Si se acepta su reclamación, recibirá por correo una tarjeta para farmacias minoristas. Presente esa tarjeta al surtir recetas posteriores
relacionadas.
Farmacias participantes:
Brooks Pharmacy
Harris Teeter Pharmacy
Rite Aid Pharmacy
CVS Pharmacy
Kmart Pharmacy
Walgreens Pharmacy
Eckerd Pharmacy
Kroger Pharmacy
Wal-Mart Pharmacy
Longs Drugs
Winn Dixie Pharmacy
Si desea conocer otras farmacias en su área, visite www.progressive-medical.com. Seleccione la opción Total Pharmacy Management
(Gestión total de farmacias) y, seguidamente, seleccione Pharmacy Locator (Localizador de farmacias). Introduzca su ciudad, estado o
código postal y haga clic en el botón del localizador. Verá una lista de todas las farmacias participantes en un área específica.
Instructions for Pharmacist:
LWP Claims Solutions, Inc. participates with Progressive Medical in an online pharmacy benefit program. This form is valid for Workers’
Compensation prescriptions only.
Please transmit all claims online to Progressive Medical:
Bin #: 600471
Process Control #: 7777
Group #: A290
For all other questions call toll-free the Progressive Medical Pharmacy Help Desk at 1-888-908-6337.
Información sobre el trabajador lesionado:
Nombre de la persona lesionada que califica:
________________________________________________
No. de ID/Autorización ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____
[Combinación del número de seguro social (9 dígitos, sin guiones) y la fecha de hoy/fecha de la lesión (6 dígitos, sin guiones); por ejemplo,
el número de seguro social 123-45-6789 y la fecha de lesión del 17 de julio de 2006 daría el número de ID 123456789071706].
Fecha de nacimiento: __________________
Sexo: ________
Empleador: ______________________________________________
For Claims Administered by Gallagher Bassett
job injury. Employees simply call the First Script number to locate a local
pharmacy where they can get their Workers Compensation prescription(s) filled.
for handing the form to the injured employee.
PRESCRIPTION PROGRAM FOR WORK-RELATED INJURIES
Welcome to First Script, a pharmacy benefit program designed exclusively for ProSight Specialty
in partnership with Gallagher Bassett Services, Inc. for your workplace injury.
Injured Worker
No Cost
STEP 1
Complete the information requested in the bottom portion below.
STEP 2
Present this form to your pharmacist along with the prescriptions for your
work-related injury.
No Delay
First Script is available at over 67,000 pharmacies nationwide. To locate a nearby
pharmacy, please call First Script Customer Service at 1-866-445-7344.
Feel Better
Faster
Please note that First Script is valid only for medications prescribed to treat your
compensable work-related injury. You or your group health insurer, are financially
responsible for any other prescriptions. The workers’ compensation carrier will
determine the compensability of the claim.
Pharmacy Instructions
The injured worker’s employer participates in First Script, a pharmacy benefit program administered by Medco. Call
the First Script Help Desk, 24 hours a day, 7 days a week, at 1-866-445-7344. If the Member ID number is not
listed on this form, please provide the claimant information indicated below to receive the Member ID #. Please
note the ID number on the form and return to injured worker. First Script claims are submitted electronically and
electronic approval of the claim will be returned.
Pharmacy: You will not be required to submit any paperwork for this claim and payment is guaranteed for all electronically accepted claims.
Pharmacy: At the request of the workers' compensation carrier for this customer, please use the
following information to process all workers' compensation prescriptions online.
Name: ____________________________________
SSN: _______-_____-________
RX PROGRAM ADMINISTERED BY: MEDCO
Date of birth: _____/_____/_____
GROUP NUMBER: FSNCVTY
State where injury occurred: ___________________
BIN NUMBER: 610014
Date of injury: _____/_____/_____
Client #: 005174
Member ID: ________________________________
Employer Name: ProSight Specialty
(Member ID # is generated at time of enrollment)
(Above information to be completed by injured worker or supervisor)
Programa de Beneficio Farmacéutico Para Accidentes Laborales
Bienvenido a First Script, un programa diseñado exclusivamente para ProSight Specialty en
asociación con Gallagher Bassett Services, Inc. para su lesión relacionada con su trabajo.
Empleado Lastimado
Ningún
Costo
Paso #1
Complete la información requerida en el formulario de la parte inferior.
Paso #2
Presente esta forma a su farmacéutico con su receta relacionada a su
accidente o lesión.
Sin
Tardanza/
Sin Demora
First Script esta disponible en más de 67,000 farmacias en todo el país. Para localizar
una farmacia cerca de usted, favor de llamar al departamento de servicios de First
Script al 1-866-445-7344.
Siéntase
Mejor Mas
Rápido
First Script es solo valido para medicinas recetadas en el tratamiento de su lesión que
sea directamente relacionada o por causa de su trabajo. Usted o su grupo de seguro
medico son responsables por cualquier otra receta. El seguro de compensación de su
trabajo determinará la compensación de su caso.
Pharmacy Instructions
The injured worker’s employer participates in First Script, a pharmacy benefit program administered by Medco. Call
the First Script Help Desk, 24 hours a day, 7 days a week, at 1-866-445-7344. If the Member ID number is not
listed on this form, please provide the claimant information indicated below to receive the Member ID #. Please
note the ID number on the form and return to injured worker. First Script claims are submitted electronically and
electronic approval of the claim will be returned.
Pharmacy: You will not be required to submit any paperwork for this claim and payment is guaranteed for all electronically accepted claims.
Pharmacy: At the request of the workers' compensation carrier for this customer, please use the
following information to process all workers' compensation prescriptions online.
Name: ____________________________________
SSN: _______-_____-________
RX PROGRAM ADMINISTERED BY: MEDCO
Date of birth: _____/_____/_____
GROUP NUMBER: FSNCVTY
State where injury occurred: ___________________
BIN NUMBER: 610014
Date of injury: _____/_____/_____
Client #: 005174
Member ID: ________________________________
(Member ID # is generated at time of enrollment)
(Above information to be completed by injured worker or supervisor)
Employer Name: ProSight Specialty
Dear Policyholder:
For your convenience, we have included the following website addresses to your state’s
Workers’ Compensation web page. From the links below, you can access any forms that
you might need when submitting a Workers’ Compensation claim.
Alabama
http://dir.alabama.gov
Kentucky
http://www.labor.ky.gov/
North Dakota
http://www.workforcesafety.com/
Alaska
http://www.labor.alaska.gov/wc/
Louisiana
http://www.laworks.net/
Ohio
http://www.ohiobwc.com/
Arizona
http://www.ica.state.az.us/
Maine
http://www.maine.gov/wcb/
Oklahoma
http://www.owcc.state.ok.us/
Arkansas
http://www.awcc.state.ar.us/
Maryland
http://www.wcc.state.md.us/
Oregon
http://www.cbs.state.or.us/wcd/
California
http://www.dir.ca.gov/dwc/
Massachusetts
http://www.state.ma.us/wcac/
Pennsylvania
http://www.portal.state.pa.us
Colorado
http://www.colorado.gov/
Michigan
http://www.michigan.gov/wca
Rhode Island
http://www.dlt.ri.gov/wc/
Connecticut
http://wcc.state.ct.us/
Minnesota
http://www.doli.state.mn.us/
South Carolina
Delaware
http://www.delawareworks.com/
Mississippi
http://www.mwcc.state.ms.us/
South Dakota
http://dlr.sd.gov/workerscomp/
DC
http://www.does.dc.gov/does/
Missouri
http://labor.mo.gov/
Tennessee
http://www.tn.gov/labor-wfd/
Florida
http://www.myfloridacfo.com/wc
Montana
http://erd.dli.mt.gov/
Texas
http://www.tdi.state.tx.us/forms/
Georgia
http://sbwc.georgia.gov/portal/
Nebraska
http://www.wcc.ne.gov
Utah
http://www.laborcommission.utah.gov/
Hawaii
http://hawaii.gov/labor/rs/
Nevada
http://dirweb.state.nv.us/WCS/wcs.htm
Vermont
http://www.labor.vermont.gov/
Idaho
http://www.iic.idaho.gov/
New Hampshire
http://www.labor.state.nh.us/
Virginia
http://www.vwc.state.va.us/portal/
Illinois
http://www.iwcc.il.gov/
New Jersey
http://lwd.state.nj.us/labor/wc/wc_index.html
Washington
http://www.lni.wa.gov/
Indiana
http://www.in.gov/wcb/
New Mexico
http://www.workerscomp.state.nm.us/
West Virginia
http://www.wvinsurance.gov/
Iowa
http://www.iowaworkforce.org
New York
www.wcb.state.ny.us
Wisconsin
http://dwd.wisconsin.gov/wc/
Kansas
http://www.dol.ks.gov/wc/about.html
North Carolina
http://www.ic.nc.gov/forms.html
Wyoming
http://doe.wyo.gov/aboutus/
http://www.wcc.sc.gov/Pages/default.aspx
California State Reporting Forms
Reporting Forms for all other states can be obtained
by accessing your state’s Workers’ Compensation
website (see previous page)
State of California
Please complete in triplicate (type if possible) Mail two copies to:
EMPLOYER'S REPORT OF
OCCUPATIONAL INJURY OR ILLNESS
OSHA CASE NO.
FATALITY
Any person who makes or causes to be made any
knowingly false or fraudulent material statement or
material representation for the purpose of obtaining or
denying workers compensation benefits or payments is
guilty of a felony.
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond the
date of the incident OR requires medical treatment beyond first aid. If an employee subsequently dies as a result of a previously reported injury or
illness, the employer must file within five days of knowledge an amended report indicating death. In addition, every serious injury, illness, or death
must be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health.
1. FIRM NAME
Ia. Policy Number
Please do not use
this column
2. MAILING ADDRESS: (Number, Street, City, Zip)
E
M
P
L 3. LOCATION if different from Mailing Address (Number, Street, City and Zip)
O
Y
E 4. NATURE OF BUSINESS; e.g.. Painting contractor, wholesale grocer, sawmill, hotel, etc.
R
6. TYPE OF EMPLOYER:
Private
County
State
7. DATE OF INJURY / ONSET OF ILLNESS 8. TIME INJURY/ILLNESS OCCURRED
(mm/dd/yy)
CASE NUMBER
3a. Location Code
OWNERSHIP
5. State unemployment insurance acct.no
City
School District
AM
INDUSTRY
Other Gov't, Specify:
10. IF EMPLOYEE DIED, DATE OF DEATH (mm/dd/yy)
9. TIME EMPLOYEE BEGAN WORK
PM
AM
1 1. UNABLE TO WORK FOR AT LEAST ONE 12. DATE LAST WORKED (mm/dd/yy)
FULL DAY AFTER DATE OF INJURY?
Yes
2a. Phone Number
OCCUPATION
PM
13. DATE RETURNED TO WORK (mm/dd/yy)
14. IF STILL OFF WORK, CHECK THIS BOX:
No
15. PAID FULL DAYS WAGES FOR DATE OF 16. SALARY BEING CONTINUED?
NJURY OR LAST
Yes
No
DAY WORKED?
Yes
No
17. DATE OF EMPLOYER'S KNOWLEDGE /NOTICE OF 18. DATE EMPLOYEE WAS PROVIDED CLAIM FORM
FORM (mm/dd/yy)
INJURY/ILLNESS (mm/dd/yy)
SEX
19. SPECIFIC INJURY/ILLNESS AND PART OF BODY AFFECTED, MEDICAL DIAGNOSIS if available, e.g.. Second degree burns on right arm, tendonitis on left elbow, lead poisoning
I
N
20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number, Street, City, Zip)
20a. COUNTY
J
U
R
Y
22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED, e.g.. Shipping department, machine shop.
AGE
21. ON EMPLOYER'S PREMISES?
Yes
DAILY HOURS
No
23. Other Workers injured or ill in this event?
Yes
No
DAYS PER WEEK
24. EQUIPMENT, MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED, e.g.. Acetylene, welding torch, farm tractor, scaffold
O
R
WEEKLY HOURS
25. SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED, e.g.. Welding seams of metal forms, loading boxes onto truck.
I
L
L 26. HOW INJURY/ILLNESS OCCURRED. DESCRIBE SEQUENCE OF EVENTS. SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS, e.g.. Worker stepped back to inspect work
N and slipped on scrap material. As he fell, he brushed against fresh weld, and burned right hand. USE SEPARATE SHEET IF NECESSARY
E
S
S
27. Name and address of physician (number, street, city, zip)
28. Hospitalized as an inpatient overnight?
No
27a. Phone Number
Yes If yes then, name and address of hospital (number, street, city, zip)
WEEKLY WAGE
COUNTY
NATURE OF INJURY
28a. Phone Number
PART OF BODY
29. Employee treated in emergency room?
Yes
No
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible
while the information is being used for occupational safety and health purposes. See CCR Title 8 14300.29 (b)(6)-(10) & 14300.35(b)(2)(E)2.
SOURCE
Note: Shaded boxes indicate confidential employee information as listed in CCR Title 8 14300.35(b)(2)(E)2*.
30. EMPLOYEE NAME
32. DATE OF BIRTH (mm/dd/yy)
31. SOCIAL SECURITY NUMBER
EVENT
33. HOME ADDRESS (Number, Street, City,Zip)
E
M
P
35. OCCUPATION (Regular job title, NO initials, abbreviations or numbers)
L 34. SEX
O
Male
Female
Y
37a. EMPLOYMENT STATUS
37. EMPLOYEE USUALLY WORKS
E
regular, full-time
E
total weekly hours
days per week,
hours per day,
temporary
SECONDARY SOURCE
36. DATE OF HIRE (mm/dd/yy)
part-time
37b. UNDER WHAT CLASS CODE OF YOUR
POLICY WHERE WAGES ASSIGNED
seasonal
EXTENT OF INJURY
39. OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (e.g. tips, meals, overtime, bonuses, etc.)?
38. GROSS WAGES/SALARY
$
Completed By (type or print)
33a. PHONE NUMBER
per
Signature & Title
Yes
No
Date (mm/dd/yy)
• Confidential information may be disclosed only to the employee, former employee, or their personal representative (CCR Title 8 14300.35), to others for the purpose of processing a workers' compensation or other insurance
. state and
claim; and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 14300.30). CCR Title 8 14300.40 requires provision upon request to certain
federal workplace safety agencies.
FORM 5020 (Rev7) June 2002
FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
State of California
Department of Industrial Relations
DIVISION OF WORKERS’ COMPENSATION
Estado de California
Departamento de Relaciones Industriales
DIVISION DE COMPENSACIÓN AL TRABAJADOR
WORKERS’ COMPENSATION CLAIM FORM (DWC 1)
Employee: Complete the “Employee” section and give the form to
your employer. Keep a copy and mark it “Employee’s Temporary
Receipt” until you receive the signed and dated copy from your em ployer. You may call the Division of Workers’ Compensation and
hear recorded information at (800) 736-7401. An explanation of workers' compensation benefits is included as the cover sheet of this form.
You should also have received a pamphlet from your employer describing workers’ compensation benefits and the procedures to obtain
them.
Any person who makes or causes to be made any knowingly false
or fraudulent material statement or material representation for
the purpose of obtaining or denying workers’ compensation benefits or payments is guilty of a felony.
Employee—complete this section and see note above
PETITION DEL EMPLEADO PARA DE COMPENSACIÓN DEL
TRABAJADOR (DWC 1)
Empleado: Complete la sección “Empleado” y entregue la forma a su
empleador. Quédese con la copia designada “Recibo Temporal del
Empleado” hasta que Ud. reciba la copia firmada y fechada de su empleador.
Ud. puede llamar a la Division de Compensación al Trabajador al (800) 7367401 para oir información gravada. En la hoja cubierta de esta
forma esta la explicatión de los beneficios de compensación al trabajador.
Ud. también debería haber recibido de su empleador un folleto describiendo los
benficios de compensación al trabajador lesionado y los procedimientos para
obtenerlos.
Toda aquella persona que a propósito haga o cause que se produzca
cualquier declaración o representación material falsa o fraudulenta con el
fin de obtener o negar beneficios o pagos de compensación a trabajadores
lesionados es culpable de un crimen mayor “felonia”.
Empleado—complete esta sección y note la notación arriba.
1.
Name. Nombre. _____________________________________________Today’s Date. Fecha de Hoy.
2.
Home Address. Dirección Residencial. _______________________________________________________________________________________
3.
City. Ciudad. _______________________________________ State. Estado. __________________
4.
Date of Injury. Fecha de la lesión (accidente). ________________________ Time of Injury. Hora en que ocurrió. _________a.m. ________p.m.
5.
Address and description of where injury happened. Dirección/lugar dónde occurió el accidente. _________________________________________
___________________________________
Zip. Código Postal. ___________________
_______________________________________________________________________________________________________________________
6.
Describe injury and part of body affected. Describa la lesión y parte del cuerpo afectada. _______________________________________________
_______________________________________________________________________________________________________________________
7.
Social Security Number. Número de Seguro Social del Empleado.
8.
Signature of employee. Firma del empleado.
_______________________________________________________________
_________________________________________________________________________________
Employer—complete this section and see note below. Empleador—complete esta sección y note la notación abajo.
9.
Name of employer. Nombre del empleador. ___________________________________________________________________________________
10. Address. Dirección. _____________________________________________________________________________________________________
11. Date employer first knew of injury. Fecha en que el empleador supo por primera vez de la lesión o accidente. _____________________________
12. Date claim form was provided to employee. Fecha en que se le entregó al empleado la petición. _________________________________________
13. Date employer received claim form. Fecha en que el empleado devolvió la petición al empleador. _______________________________________
14. Name and address of insurance carrier or adjusting agency. Nombre y dirección de la compañía de seguros o agencia adminstradora de seguros.
_______________________________________________________________________________________________________________________
15. Insurance Policy Number. El número de la póliza de Seguro. _____________________________________________________________________
16. Signature of employer representative. Firma del representante del empleador. _______________________________________________________
17. Title. Título. _____________________________________ 18. Telephone. Teléfono. _______________________________________________
Employer: You are required to date this form and provide copies to
your insurer or claims administrator and to the employee, dependent
or representative who filed the claim within one working day of
receipt of the form from the employee.
Empleador: Se requiere que Ud. feche esta forma y que provéa copias a su compañía de seguros, administrador de reclamos, o dependiente/representante de reclamos y al empleado que hayan presentado esta petición dentro del plazo de un día
hábil desde el momento de haber sido recibida la forma del empleado.
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
❑ Employer copy/Copia del Empleador
6/10 Rev.
❑ Employee copy/ Copia del Empleado
❑ Claims Administrator/Administrador de Reclamos
❑ Temporary Receipt/Recibo del Empleado

Claims Kit - ProSight Specialty Insurance

Transcripción

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