WORKERS' COMPENSATION PACKET

Transcription

1 KATY INDEPENDENT SCHOOL DISTRICT WORKERS' COMPENSATION PACKET 2017/ IF YOU ARE INJURED AT WORK A. INSTRUCTIONS ON WHAT TO DO AFTER A WORK INJURY B. APPROVED AREA WORKERS' COMP DOCTORS/CLINICS 2. EMPLOYEE ACKNOWLEDGEMENT OF THE ALLIANCE A. EXPLANATION OF OUR WORKERS' COMP NETWORK OF DOCTORS B. MUST BE COMPLETED AND RETURNED WITHIN 7 DAYS OF INJURY 3. STAND-ALONE ER CLINICS NOT APPROVED AND LIST OF LOCAL APPROVED CLINICS 4. TEMPORARY INCOME BENEFITS 5. OFFSET PROCEDURES/WAGE BENEFITS A. MUST BE COMPLETED AND RETURNED WITHIN 7 DAYS OF INJURY 6. RETURNING TO WORK AFTER A WORK RELATED INJURY 7. FIRST FILL CARD 8. OFFICE OF INJURED EMPLOYEE COUNSEL (OIEC)

2 Katy Independent School District Risk Management Department or (fax ) IF YOU ARE INJURED AT WORK Revised June 2017 Follow these 3 easy steps 1. Immediately report the incident/injury to your Principal or an Assistant Principal unless you are an hourly employee (custodians, bus drivers, food services, maintenance, etc). Hourly employees are to report to their immediate supervisor. Failure to report an accident within 30 days could cause your claim to be denied by our workers' compensation claims administrator according to Texas Department of Insurance, Division of Workers' Compensation rules and regulations. 2. Contact campus nurse if available for injury assessment and initial minor treatment. If further medical treatment is needed notify Risk Management Department prior to seeking medical treatment. If you chose and mark one of the approved doctors on the accident report, that is notification. If you do not chose one and later decide you need medical treatment, you must notify Risk Management before seeking medical treatment. 3. Complete and Submit the KISD online accident report by going to KatyNet, Online Forms, "Employee First Report of Injury and Required Paperwork". If you are unable or unavailable to submit the accident report, then it is your supervisor's responsibility to submit the accident report. Submitting the report prior to seeking medical treatment and within 24 hours of the incident/injury is critical for proper handling. You will need to take a copy of the report and a picture ID to the doctor's office before they will treat you for a work related injury. Of course if the injury is a life threatening medical emergency, call 911. Contact Risk Management as soon as possible, or We will attempt to meet with you and the hospital staff in the hospital emergency room. If the injury is compensable (accepted by our claims administrator), you should not have to pay anything. **Send a copy of your hospital release paperwork to Lindy Shorthose, ESC 1540, Risk Management. Other than emergency care in a hospital emergency room, all medical treatment for work related injures must be from an approved provider on our workers' compensation network, Political Subdivision of Workers' Compensation Alliance (The Alliance). A link to The Alliance doctor directory is on the online form, First choose a primary care doctor from the directory as your treating doctor. The treating doctor will direct your care for the duration of needed medical treatment of your injury. If you miss any time from work due to the injury, even leaving work early, or seeking medical treatment you must have an Alliance doctor' s release to return to work. If the doctor has prescribed restrictions, then that has to be approved prior to you returning to work. Contact Risk Management who will obtain approval from the appropriate sources (Human Resources, Campus or Department Administration).

3 Reasonable and necessary treatment including medications for a compensable injury will be paid by the District through our claims administrator. A one-time use "First Fill" card is provided to you by Risk Management to get your first workers' compensation prescription filled. If continuing prescriptions are required, the claims administrator will send you a card. The Alliance Primary Care doctors in the area are as follows. You can find other doctors and other locations on the website, APEX URGENT CARE: No appointment needed, 6111 N. Fry Rd, Katy, TX Open 9am - 9pm Monday - Friday and 9am - 6pm Saturday/Sunday CONCENTRA CLINIC: No appointment needed, Katy Freeway, Houston, TX Open 7am - 9pm Monday - Friday and 8am - 6pm Saturday/Sunday If needed clinic will provide transportation. Supervisor: Call clinic at punch O then ask for Bri or Martha to request pickup (must provide employee name, employee/supervisor phone number and address of pickup location). EXCEL URGENT CARE: No appointment needed, Katy Freeway, Houston, TX Open 9am - 9pm daily MEDSPRING: No appointment needed, 6501 S. Fry Rd, Katy, TX Open 9am - 9pm daily NEXT LEVEL URGENT CARE: No appointment needed, Spring Green Blvd, Suite 600, Katy, TX Open 9am to 9pm daily DR. NIMESH PATEL: Call to make an appointment, 702 S. Peek Rd, Katy, TX Open 8:30am - 6:30pm Monday & Thursday 8:30am - 5:30pm on Tuesday & Wednesday 7am - 1pm Friday

4 KATY INDEPENDENT SCHOOL DISTRICT EMPLOYEE ACKNOWLEDGEMENT OF THE ALLIANCE DIRECT CONTRACTING PROGRAM I have received information that tells me how to obtain health care under the Katy ISD Workers' Compensation program. If I am hurt on the job and live in a service area described in this information, I understand that: 1. I must choose a treating doctor from the Alliance list of doctors designated as Primary Care doctors. 2. My Alliance treating doctor will direct all medical care for my work related injury. 3. If I need a specialist, my treating doctor will refer me. If I need emergency care, I may go to any emergency room at a hospital (most stand-alone emergency rooms or urgent care clinics are not approved for emergency care). 4. Even though my treating doctor should refer me to a specialist from the providers contracted with the Alliance, I understand that it is my responsibility to verify that the referral doctor is a current active member of the Alliance provider panel. 5. The District through our claims administrator, Texas Association of School Boards (TASB) Risk Management Fund, will pay the treating doctor and other Alliance providers for reasonable and necessary medical treatment related to my compensable injury. 6. If I receive medical treatment from a provider other than an Alliance provider without prior approval from TASB, I may be responsible to pay 100% of the bill. It is unlikely and I understand most medical insurance, including the voluntary insurance offered through Katy ISD, specifically excludes coverage of medical treatment for work related injuries. 7. If I want to change doctors after my first choice, I understand that I must contact my assigned TASB adjuster for approval. SIGNATURE: PRINT NAME: DATE: KISD ID OR SSN: EMPLOYER: KATY INDEPENDENT SCHOOL DISTRICT NAME OF DIRECT CONTRACTING PROGRAM : POLITICAL SUBDIVISION WORKERS' COMPENSATION ALLIANCE (''The Alliance"). Link to website, is on the Online Form, " Employee First Report of Injury and Required Paperwork". Three (3) approved primary care doctors are listed on the accident report. If you mark/choose one on the accident report and submit, that will be notification to Risk Management. If you file a record only report by choosing " No medical treatment needed at this time" and decide you need medical treatment later, then you must contact Risk Management with your choice of doctor BEFORE you go to the doctor. COMPLETE AND RETURN WITHIN 7 DAYS OF THE DATE OF INJURY TO: KISD, ATTN: LINDY SHORTHOSE RISK MANAGEMENT, ESC 1540 P.O. BOX 159, KATY, TEXAS FAX OR SCAN TO lindygshorthose@katyisd.org Revised: June 2017

5 0 Stand-alone ER clinics are NOT approved on the Workers Compensation Alliance Network. YOU will be re$ponsible for any charges incurred as a result of a workrelated injury. If you are injured on the job, select a treating doctor from the approved network ER Clinics (not approved) Local Approved Clinics FIRST CHOICE MRRGlliNCV... ROOM KATY0ilttil;(ij:jmnCENTE R ~ 1.. PartnERs 'ii-' FMFRGFNCY CENTER!:, SPHIERa Concent ra ~<:>L!) EXCEL 1 (!]~\!) URGENT CARE MedSpring O urgent care nextl 1Y ] I KA TY FAMILY PHYSICIANS (Convenience Care Center - Katy)

6 TEMPORARY INCOME BENEFITS If you are off work due to a compensable work related injury for more than seven (7) calendar days, you will receive 70% of your pre-injury average weekly wage or the maximum of $913 per week, whichever is less. in the form of Temporary Income Benefits (TIBs) for injuries occurring on 10/1/16 through 9/30/17. Compensability is determined by our claims' administrator according to the rules and regulations set by the Texas Department of Insurance, Division of Workers' Compensation, Title 28, Texas Administration Code Part II ( Texas Labor Code, Title 5 and the Official Disability Guidelines (ODG). Please be aware that while you are off work due to a work injury, you will not receive a District paycheck, unless you have completed and returned the Offset Procedure Letter to Risk Management within 7 days of the injury. You may choose to use your accumulated personal sick leave, vacation days, and/or compensatory time to offset your temporary income wages. This will allow you to receive up to but no more than 100% of your pre-injury average weekly wage. If there is an overpayment of TIBs, it is the employee's responsibility to re-pay the District. Please be aware that no deductions are taken out of your TIBs check. Therefore, you are responsible to continue paying your insurance premiums. If you are absent for an extended period oftime, Risk Management will bill you. Also, there are no contributions to Texas Teacher Retirement System (TRS) and your days off do not count toward your years of service with TRS. To ensure that funds are being contributed to TRS for your retirement, you must contact TRS at and make arrangements to contribute to your retirement annuity fund. Revised 2017

7 KATY INDEPENDENT SCHOOL DISTRICT RISK MANAGEMENT DEPARTMENT Offset Procedures/Workers' Compensation Wage Benefits TDI-DWC Rule Entitlement to Temporary Inco me Benefits (a) Once temporary income benefits (TIBs) accrue, an injured employee is entitled to TlBs to compensate the employee for lost wages due to the compensable injury during a period in which the employee has disability and has not reached maximum medical improvement (MMI). (b) Lost wages are the difference between the employee's gross average weekly wage (A WW) and the employee's gross Post-Injury Earnings (PIE). If the employee's PIE equals or exceeds the employee's A WW, the employee has no lost wages. Employee Choice: If I am absent from duty because of a job-related illness or injury, I understand that I am not eligible for workers' compensation weekly income benefits until my absence exceeds seven (7) calendar days. Therefore, I choose the following for the first week of absence. Choose one (1) of the fo llowing options: LJ I choose to use only (circle one) I or 2 or 3 or 4 or 5 days of available paid leave at this time to use for first week.. LJ LJ I choose to use all available paid leave. During the first seven (7) calendar days, my leave will be used in full day increments. I also understand I am not allowed to receive more than 100% of my average daily and/or weekly wage under this agreement. I choose not to use any available paid leave at this time. I understand that I will not receive any regular salary from Katy Independent School District while receiving weekly income benefits under workers' compensation. No available paid leave will be deducted from my leave balance. I further understand that by selecting this option I wi ll receive on ly workers' compensation income benefits for any absences resulting from my work related il lness or injury unless and until I communicate, to the District, a change in my decision. A change MUST be received before payroll deadline. If you are absent from duty because of a work related injury or illness for more than 14 days, workers' compensation income benefits will be paid for your first seven (7) days of absence unless you have used your sick leave or any other available paid leave for any portion of the first seven days. THIS FORM MUST BE RETURNED TO THE RISK MANAGEMENT OFFICE WHETHER YOU LOSE TIME FROM WORK OR NOT. Workers' Compensation Benefits are paid as a percentage (70%) of you average weekly wage based on wages earned 13 weeks prior to the injury, but may not exceed the maximum weekly rate of $913 per week (for injures occurring 10/1 /2016 thru 9/30/17) set by the State. Date of Injury: Campus/Dept: ' Print Name: Signature: SSN: Date signed: RETURN WITHIN 7 DAYS OF THE DA TE OF INJU RY TO: KATY ISD (ATTN: LINDY SHORTHOSE) RISK MANAGEMENT, ROOM 1540 ESC P.O. BOX 159, KA TY, TEXAS OR , FAX: Revised: June 2017

8 I RETURNING TO WORK AFTER WORK RELATED ACCIDENT /INJURY ABSENCE I I I If you have any lost time (including leaving work early) or receiving medical treatment directly due to a work related injury, a Workers' Compensation Network doctor's release (Work Status Report, DWC form 73) is required before an injured worker can return to work. If the doctor prescribes restrictions contact Risk Management immediately. Risk Management will obtain approval from appropriate designated administrators. A determination to approve or deny modified duty return to work is based on injured employee's job description and specific job assignment. If modified duty is approved, the employee will be sent a Bona Fide Offer of Modified Duty Employment letter. The employee has the choice to accept or decline the offer. If the employee declines the offer of modified duty, eligibility for temporary income benefits may be lost. It is the injured employee's responsibility to make sure that Risk Management receives the Work Status Report. It can be faxed immediately to Risk Management Department by fax or by scanning report to lindygshorthose@katyisd.org. Please refer to Employee Handbook and Board Policy for most current Katy ISD policies and procedures. Revised 2017

9 OPTUM. TASBR1SK MANAGEMENT FUND ~ Optum PO Box Tampa, FL MAKING IT EASY... TO GET WORKERS' COMPENSATION PR ESCRIPTIONS FILLED. Optum has been chosen to manage your workers' compensation pharmacy benefits for TASB Risk Management Fund. Below is your First Fill card that will allow you to receive your injury-related prescriptions at your local pharmacy. Please fill out the card based on the instructions below. Injured Employee: If you need a prescription filled for a work-related injury or illness, go to an Optum TmesyS- network pharmacy. Give this temporary card to the pharmacist. The pharmacist will fill your prescription at low or no cost to you. If your workers' compensation claim is accepted, you will receive a more permanent pharmacy card in the mail. Please use that card for other work-related injury or illness prescriptions. Most pharmacies, including Walgreens, our preferred provider, and all major chains, are included in the network. To find a network pharmacy call or visit t mesys.com. Questions? Need Help? CJ TASB Rlak Management Fund CARRIER/IPA INJU RED WORKER NAME PINN provide directly to Phannaclsl SOCIAL SKUR!TY NUMBER Katy ISO EMPI.OYER DATE OF INJURY (YYMMOD) Notlce to cardholder: Present this card to the pharmacy to receive medication for your work-rwi.ted Injury. To locate a ph41rmacy. tmesys.com. Attention PhanNldsb: Enter RxBIN, RxPCN and GROUP. Member ID t format is the date of Injury and SSN combined IS follows: YYMMDD Tmesyo is t he designated PBM for this patient This card is not valid for compound medications. Tmesys Pharmacy Help Desk RxBIN RxPCN GROUP llllx fnlll2ll or CAL or Envoy Acct. # TASBFF NOTE: This First Fill card is only valid for your workers' compensation injury or illness. Employer: Immediately upon receiving notice of injury, fill in the information above and give this form to the employee. The following entities comprise 1he Optum Workers Compensation and Auto No Fault division: PMS!, UC, dba Optum Worlters Compensation Services of Florida; Progressille Medical, UC. dba Optum Worlcers Compensation Services of Ohio; CyprMS Care, Inc. dba Optum Workers Compensation Services of Gt0r9a; Healthcare Solutions, Inc., dba Optum Healthcare Solutions of Georgia; Settlement Solutions, UC, dba Optum Settlement Solutions; Procura Management. Inc., dba Optum Managed Care Services; Modern Medical, dba Optum Workers Compensation Medical Services, collecthlely and Individually referred as optum. tmesys IMP

10 ~ O_ FF_I_C_E_O_F_IN_JURE D_E_M_P_L_O_Y_EE_ C_O_UN_ SE_L Notice of Injured Employee Rights and Responsibilities in the Texas Workers' Compensation System As an injured employee in Texas, you have the right to free assistance from the Office of Injured Employee Counsel (OIEC). This assistance is offered at local offices across the State. These local offices also provide other workers' compensation system services from the Texas Department of Insurance (TDI). TDI is the State agency that administers and regulates the workers' compensation system through the Division of Workers' Compensation (DWC). Many services provided by OIEC and DWC can be completed over the telephone. You can contact OIEC by calling the toll-free telephone number EZE-OIEC (l ). Additional information, including office locations, is available on the Internet at: You can contact DWC by calling the toll-free telephone number Information about DWC is available on the Internet at: Your Rights in the Texas Workers' Compensation System: 1. You have the right to hire an attorney to help you with your workers' compensation claim. For assistance locating an attorney, contact the State Bar of Texas' lawyer referral service at or Attorney referral information can also be found on OIEC' s website at 2. You have the right to receive assistance from OIEC if you do not have an attorney. OIEC Customer Service Representatives and Ombudsmen are available to answer your questions and provide assistance with your workers' compensation claim by calling OIEC or visiting an OIEC office. You must sign a written authorization before an OIEC employee can access information on your claim. Call or visit an OIEC office to fill out the written authorization. Customer Service Representatives and Ombudsmen are trained in the field of workers' compensation and can help you with scheduling a dispute resolution proceeding about your workers' compensation claim. An Ombudsman can also assist you at a benefit review conference (BRC), contested case hearing (CCH), and an appeal. However, Ombudsmen cannot make decisions for you or give legal advice. 3. You may have the right to receive medical and income benefits regardless of who was at fault for your injury, with certain exceptions. Your beneficiaries may be entitled to death and burial benefits. Information about the exceptions can be found at or by visiting with OIEC staff. 4. You may have the right to receive medical care to treat your workplace injury or illness for as long as it is medically necessary and related to the workplace injury. You may have the right to reimbursement of your incurred expenses after traveling to attend a medical appointment or required medical examination if the trip meets qualifying conditions. 5. You may have the right to receive income benefits for your work-related injury. There are several types of income benefits and eligibility requirements. Information on the types of income benefits that may be available and the eligibility requirements can be found at or by visiting with OIEC staff. 6. You may have the right to dispute resolution regarding income and medical benefits. You may request Medical Dispute Resolution if you disagree with the insurance carrier regarding medical benefits. You may request Indemnity (Income) Dispute Resolution if you disagree with the insurance carrier regarding income benefits. The law provides that your dispute proceedings will be held within 75 miles from your residence. 7. You have the right to choose a treating doctor. If you are in a Workers' Compensation Health Care Network (network), you must choose your doctor from the network's treating doctor list. You may change your treating doctor once without network approval. If you are not in a network, you may initially choose any doctor who is willing to treat your workers' compensation injury; however,

11 changing your treating doctor must be pre-approved by the DWC if you are not in a network. If you are employed by a political subdivision (e.g. city, county, school district,) you must follow its rules for choosing a treating doctor. It is important to follow all the rules in the workers' compensation system. If you do not follow these rules, you may be held responsible for payment of medical bills. OIEC staff can help you to understand these rules. 8. You have the right for your workers' compensation claim information to be kept confidential. In most cases, the contents of your claim file cannot be obtained by others. Some parties have a right to know what is in your claim file, such as your employer or your employer's insurance carrier. Also, an employer that is considering hiring you may get limited information about your claim from DWC. Your Responsibilities in the Texas Workers' Compensation System 1. You have the responsibility to tell your employer if you have been injured at work while performing the duties of your job. You must tell your employer within 30 days of the date you were injured or first knew your injury or illness might be work-related. 2. You have the responsibility to know if you are in a Workers' Compensation Health Care Network (network). If you do not know whether you are in a network, ask the employer you worked for at the time of your injury. If you are in a network, you have the responsibility to follow the network rules. If there is something you do not understand, ask your employer or call OIEC. If you would like to file a complaint about a network, call TDI' s Customer Help Line at l or file a complaint online at 3. If you worked for a political subdivision (e.g., city, county, school district) at the time of your injury, you have the responsibility to find out how to receive medical treatment. Your employer should be able to provide you with the information you will need in order to determine which health care providers can treat you for your workplace injury. 4. You have the responsibility to tell your doctor how you were injured and whether the injury is work-related. 5. You have the responsibility to send a completed Employee's Claim for Compensation for a Work-Related Injury or Occupational Claim Form (DWC041) to DWC. You have one year to send the form after you were injured or first knew that your illness might be work-related. Send the completed DWC041 form even if you already are receiving benefits. You may lose your right to benefits if you do not timely send the completed claim form to DWC. For a copy of the DWC04 l form you may contact DWC or OIEC. 6. You have the responsibility to provide your current address, telephone number, and employer information to DWC and the insurance carrier. DWC can be contacted at You have the responsibility to tell DWC and the insurance carrier anytime there is a change in your employment status or wages. (Examples of changes include: you stop working because of your injury; you start working; or you are offered a job). 8. Eligible beneficiaries or persons seeking death and burial benefits have the responsibility to send a completed Beneficiary Claim for Death Benefits (DWC~042) to DWC within one year following the employee's date of death. 9. You are prohibited from making frivolous or fraudulent claims or demands. REV. 06/2012 2