TABLE OF CONTENTS 1. SENTRY CLAIM REPORTING PROCEDURES 2. INSURANCE FRAUD PROTECTION 3. AMERICANS WITH DISABILITIES ACT 4. MANAGED MEDICAL CARE

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1 TABLE OF CONTENTS 1. SENTRY CLAIM REPORTING PROCEDURES 2. INSURANCE FRAUD PROTECTION 3. AMERICANS WITH DISABILITIES ACT 4. MANAGED MEDICAL CARE 5. SENTRY UTILIZED- WORKERS' COMPENSATION MEDICAL NETWORKS FREQUENTLY ASKED QUESTIONS 6. HOW TO CREATE WORKSITE POSTERS 7. RETAIL PRESCRIPTION PROGRAM 8. TREATMENT AUTHORIZATION FORMS /25/2017

2 1. SENTRY CLAIM REPORTING PROCEDURES Timely reporting of accidents and injuries is critical. Prompt reporting improves claim handling by allowing investigations to start sooner, prevents the loss of critical evidence, encourages prompt resolution of claims and potentially reduces claim costs. All losses should be reported immediately, even if all information is not available. Losses can be reported by phone, fax, or internet 24 hours a day/365 days a year. The Reporting Guide on the following pages will assist you with the questions that will be asked when reporting by phone. To expedite reporting, please have your policy or account number available. WORKERS' COMPENSATION By Phone or Internet: o Obtain information regarding the injury o Log on to o Call SENTRY ( ) Option 1 o Where permitted, Sentry will file the First Report of Injury with the state. A copy will be sent to you. o Please inform the injured employee that Sentry may contact them for more details regarding the injury. By Fax: o Complete your state specific First Report of Injury. o Fax a copy of the First Report of Injury to Please use the enclosed FA cover sheet. o Keep a copy for your records. To send correspondence by mail (Workers Compensation): Sentry Claims Service Attn: Medical Cost Containment Unit 2225 Minnesota Ave. P.O. Box 8032 Stevens Point, WI GENERAL LIABILITY AUTO PRODUCTS ENVIRONMENTAL PROPERTY By Phone or Internet: o Obtain information regarding the injury o Log on to o Call SENTRY ( ) Option 1 By Fax: o Fax all information regarding the loss to To send all other correspondence by mail (all claim types): Sentry Claims Service 2225 Minnesota Avenue P.O. Box 8026 Stevens Point, WI

3 WC A GL Claimant Information Date of Accident Social Security number Last/first/middle name Sex Date of birth Street address City/state/ZIP code Phone number Marital status Number of dependents Occupation Medical Information Name of physician or clinic Address/city/state/ZIP code of physician Physician's phone number Coverage Information Insurance policy number Insurance policy effective/expiration date Corporate name Corporate mailing address Corporate phone number Reporting location name Reporting location full mailing address Reporting location phone number Employer's federal ID number Location code Accident Information Time of injury Accident description Did accident occur on your premises Accident location City/state/ZIP code Witnesses Last day worked Date returned to work Did employee die Date employer notified of injury Date of hire/state of hire Class code Body part Injury description WC A GL Wage Information Average hours per day/per week Average days per week worked Other compensation (room, board, tips) Full pay last day worked Salary continued Hourly wage rate General Liability Owner of premises Owner's address, other than insured Type of product Name of manufacturer, other than insured Manufacturer's address/phone number Auto Information Police Report Violations or citations Vehicle year/make/model/body type Vehicle Information Number (VIN) Vehicle plate number/tag state Owner's (insured vehicle name/address) Owner's home phone/business number Driver's name/address Driver's home phone/business number Driver's relation to injured Driver's date of birth Driver's license number/state Purpose of use Describe damage and point of impact Estimate amount of damage Claimant insurance information Passengers Caller/Contact Information Caller name Caller title Caller phone number Contact name Contact title Contact phone number Best time for contact during the day WC A GL Workers' Compensation Auto General Liability LOCATION AND DEPARTMENT CODES Your company may have established location and department codes. Please provide the appropriate code when reporting a claim. It is extremely important to utilize correct coding to properly identify your claim trends. Please contact your risk manager to verify the codes for your location. 3

4 2. INSURANCE FRAUD PREVENTION Fraudulent insurance claims cost American businesses more than $18 billion per year. Sentry Insurance has taken a leadership role in the fight against fraudulent claims. Our fraud prevention program includes special investigative units (SIUs) which examine potential fraud in the claim processing stage and immediate response to suspected fraudulent claims. Anti-insurance fraud programs are successful only if supported by employers, who stand the most to gain by a reduction in fraudulent activities. IF YOU SUSPECT A FRAUDULENT WORKERS COMPENSATION CLAIM Call your Sentry claim representative, or SENTRY ( ), immediately. Sentry will initiate a thorough and confidential investigation. INSURANCE FRAUD RED FLAGS Below are red flags which may point to possible fraud in a Workers Compensation claim: Injured worker took unexplained or excessive time off prior to injury Injured worker has a history of reporting subjective injuries Incident occurs near the end or near the beginning of the workweek Incident is unwitnessed Incident occurs outside normal work area Injured worker gives conflicting accounts about the incident After the incident, injured worker is difficult to reach by phone Rumors circulate through the workplace that the incident was not legitimate Incident occurs just prior to a strike or near the end of a probationary period Details of the accident are vague or contradictory Injured worker has a high deductible or no healthcare insurance 4

5 3. AMERICANS WITH DISABILITIES ACT When one of your employees files a claim for Workers' Compensation benefits due to a reported workplace injury, as your insurer, Sentry will review the claim and pay those benefits which we determine are due. If appropriate, Sentry will also assist your employee in returning to work. Please note that, if the employee's injury qualifies as a disability under the Americans with Disabilities Act (ADA), you may be obligated to provide reasonable accommodations to assist the employee's return to work and/or performance of his or her essential job duties. Further, in the event of a dispute, your employee might seek disclosure of Sentry's Workers' Compensation records regarding efforts to return the employee to work. When appropriate, Sentry negotiates lump-sum settlements of Workers' Compensation claims. Such settlements do not include a waiver of ADA or any other employment law-related claims. Any waiver or settlement of ADA or employment law claims is your responsibility. Please notify your Workers' Compensation claims representative if you will be attempting to settle ADA or employment law-related issues. ADA and other employment law settlements and costs are your responsibility and are not covered under your Workers' Compensation policy. If you have any questions, please contact one of our claims representatives. 5

6 4. MANAGED MEDICAL CARE The medical portion of your Workers' Compensation insurance represents a substantial portion of benefits dollar paid. The Sentry utilized Workers' Compensation Medical Network offerings are an important tool that can help control medical expenses. The Sentry utilized Workers' Compensation Medical Network offerings include hospitals, doctors, specialists, outpatient facilities, and other medical care providers which charge a lower fee for patients covered by a Sentry Insurance Workers' Compensation plan. When your injured employees use a medical provider who is part of the network, you help control one of the primary factors driving up the cost of Workers' Compensation insurance. HOW YOU CAN CONTROL MEDICAL EPENSES AND REDUCE YOUR INSURANCE COSTS 1. Encourage injured employees to seek treatment from members of the Sentry utilized Workers' Compensation Medical Network offerings. Your employees receive high quality medical care, and you'll benefit from prenegotiated rates that can decrease medical costs by 10 to 20 percent. 2. In some states, you are allowed to direct the injured worker to a preselected physician for a limited period of time, if you post the names of those doctors in a readily visible area. These states include AL, CO, FL, GA, IA, ID, IN, KS, ME, MI, MO, NJ, NM, NC, PA, SC, TN, UT, VT, and VA. 3. If your State Workers' Compensation law does not allow you to direct an injured worker to a preselected physician, the injured employee may still appreciate your help in identifying a qualified care provider. However, never infringe on the legal right of injured workers to select their own physicians. 4. Express concern for your employees' wellbeing throughout their recovery. Let them know that medical bills related to the injury will be paid, and they will have a job waiting for them following their recovery. Your reassurance can eliminate stress, which may interfere with their medical progress. 5. California authorizes establishment of Medical Provider Networks to provide WC Medical Benefits. The state specific information enclosed will provide additional detail in regard to the Sentry Medical Provider Network. 6

7 5. THE SENTRY UTILIZED WORKERS' COMPENSATION MEDICAL NETWORK OFFERINGS Frequently Asked Questions QUESTION: ANSWER: What will the Sentry utilized Workers' Compensation Medical Network offerings do for me? It is an excellent tool to control medical expenses, which in turn allows Sentry to provide you with significant, long-term savings. Medical care costs are a function of both volume and price per unit. By establishing contracts with hospitals, physicians, and outpatient care providers over a multiyear period, we obtain caps on annual increases and substantial discounts for our insureds who receive treatment from participating members. QUESTION: ANSWER: Must my employees seek medical treatment only from members of the Workers' Compensation Medical Network offerings? No. Depending on your State Workers' Compensation laws, your employees may receive treatment either from a provider you select or from their choice of provider. You should encourage an injured employee to use a specific participating provider in the Workers' Compensation Network offerings by placing worksite posters in each of your locations. Your employees will receive high quality medical care, and you'll benefit from the prenegotiated rates that can decrease your medical costs by 15 percent or more. QUESTION: ANSWER: QUESTION: ANSWER: QUESTION: ANSWER: What forms or procedures do I follow to qualify for the discounts offered by the Sentry utilized Workers' Compensation Medical Network offerings? There are no additional forms. Participating providers automatically accept contractual rates for employees covered by a Sentry Workers' Compensation plan. How can I find out if a hospital or doctor is a participating member of the Workers' Compensation Medical Network offerings? You may access participating providers and create a customized worksite poster by visiting the Web Site at Instructions for accessing participating providers in your area are provided. Or, you may call to request the name of providers. Can I recommend a doctor or hospital to become a part of the Workers' Compensation Medical Network offerings? Yes. Contact your Sentry sales representative with the name of the provider. To become part of the network, the provider must meet quality assurance requirements, agree to annual cap increases, and negotiate fixed rates of reimbursement for services delivered. 7

8 6. HOW TO CREATE WORKSITE POSTERS To create a worksite poster to display participating providers close to your business: Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Visit the Workers' Compensation Web site, Choose the Worksite Poster option. Enter Employer Name, Location ID, Address, City/State/Zip, Phone, Fax and document name. Create Worksite Poster action button. Edit or add providers or provider categories through the Add Category, Search and Add new action buttons. Select Create Provider Panel action button. , Print or Fax Worksite poster directly from the site. 8

9 7. RETAIL PRESCRIPTION PROGRAM Sentry Insurance is pleased to provide a pharmacy benefits program that can help reduce your Workers Compensation costs Healthesystems. Healthesystems applies extensive clinical expertise along with workflow-driven technology to improve claims outcomes, increase efficiency, and reduce the total cost of prescription drugs while raising the quality of care for injured workers. This program includes: A First Fill program Comprehensive drug utilization review applied to all retail, mail-order, and paper transactions Efficient processes to minimize third-party billing A network with more than 60,000 participating pharmacies 24/7 multilingual support We have enclosed the following forms: First Fill program introductory letter Injured worker First Fill prescription form (for duplication as needed) A partial listing of participating pharmacies If you have any questions, contact Healthesystems at , Sentry Insurance at SENTRY ( ), or your sales representative. 9

10 W Lemon Street, Suite 311 Tampa, FL p: f: Dear Policyholder, Sentry Insurance has selected Healthesystems to provide pharmacy benefits to Workers Compensation clients. Healthesystems will be our pharmacy network vendor for both retail and mail order pharmacy. The Healthesystems retail pharmacy network allows injured workers to have their work-related medications filled at a local pharmacy with no out-of-pocket expense and at a discounted rate within the guidelines of the applicable Workers Compensation fee schedule or carrier contracted rates. As we strive to increase our utilization of Healthesystems to include initial prescriptions, we have implemented a First Fill program. Our First Fill program offers the following benefits: No out-of-pocket expenses for the injured worker Minimizes the use of non-network pharmacies Ensures network savings on the first fill and future prescriptions Dispensing of medications for a new injury frequently takes place within hours after the injury occurs and before the first notice of injury has been fully processed. In situations where the medication prescribed is on our standard formulary and it is within 30 days of the date of injury, Healthesystems will allow the pharmacy to provide a 10-day supply to the injured worker. The First Fill program allows for injured worker's first prescription drug claims to be electronically captured, processed, and adjudicated. If a notice of loss is not received or the claim is deemed noncompensable, Healthesystems will cover the cost of the 10-day supply with no charge to you or the injured worker. We have enclosed a First Fill form for newly injured workers to give to the pharmacy for processing first-time prescriptions. If you have any questions regarding the First Fill program, please contact the Healthesystems Help Desk at

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13 NETWORK PHARMACIES To access a full list of participating pharmacies you may call the HealtheSystems Help Desk at or visit A AND P PHARMACY FRYS PHARMACY PROFESSIONAL PHARMACY ACME PHARMACY GENOA HEALTHCARE PUBLI PHARMACY ALBERTSONS PHARMACY GENUARDIS PHARMACY QFC PHARMACY ARBOR DRUGS INC GIANT EAGLE PHARMACY QOL MEDS AURORA PHARMACY GIANT PHARMACY RAINBOW FOODS BARTELL DRUGS H E B PHARMACY RALEYS DRUG CENTER BASHAS UNITED DRUG HANNAFORD PHARMACY RALPHS BEL AIR PHARMACY HAPPY HARRYS DISCOUNT DRUG RALPHS PHARMACY BI-LO PHARMACY HARRIS TEETER PHARMACY RANDALLS PHARMACY BI-MART DRUGS HARVARD COMM HEALTH PLAN PHCY RECEPT PHARMACY BROOKS MAI DRUG HARVEST FOODS PHARMACY RITE AID PHARMACY BROOKS PHARMACY HARVEYS SUPERMARKET PHARMACY SAFEWAY PHARMACY BROOKSHIRE BROTHERS PHARMACY HEB PHARMACY SAMS PHARMACY BROOKSHIRE PHARMACY HOMELAND PHARMACY SAVE MART PHARMACY BRUNOS PHARMACY HOMETOWN PHARMACY SAV-ON DRUGS CARRS QUALITY CENTER HY-VEE PHARMACY SAV-ON PHARMACY CENTRAL PHARMACY INGLES PHARMACY SCHNUCKS PHARMACY CITY DRUG STORE K MART PHARMACY SHAWS PHARMACY CITY MARKET PHARMACY KASH N' KARRY FOOD SHOP N SAVE PHARMACY CLINIC PHARMACY KELTSCH PHARMACY SHOPKO PHARMACY COBORNS PHARMACY KERR DRUG SHOPPERS PHARMACY COMMUNITY PHARMACY KING KULLEN PHARMACY SHOPRITE PHARMACY COSTCO PHARMACY KING SOOPERS PHARMACY SMITHS PHARMACY CUB PHARMACY KINGS PHARMACY SNYDER DRUG CVS KINNEY DRUGS STAR PHARMACY CVS BDI INC KINNEY DRUGS INC STOP & SHOP PHARMACY CVS PHARMACY KROGER PHARMACY SUPER 1 PHARMACY DILLON PHARMACY-KS LEWIS FAMILY DRUG SUPER D DRUGS DISCOUNT DRUG MART LONGS DRUG STORE SUPER D EPRESS R DOMINICKS PHARMACY MARCS PHARMACY SUPER FRESH PHARMACY DRUG EMPORIUM MARSH DRUGS LLC TARGET PHARMACY DRUG FAIR MARTINS PHARMACY THE DRUG STORE DRUG TOWN MEDICAL ARTS PHARMACY THE PHARM DRUG WAREHOUSE MEDICAL CENTER PHARMACY THE PRESCRIPTION SHOP DUANE READE MEDICAP PHARMACY THRIFTY WHITE DRUG EATON APOTHECARY MEDICINE SHOPPE PHARMACY TOM THUMB PHARMACY ECKERD DRUG MEIJER PHARMACY TOPS PHARMACY FAGEN PHARMACY MINYARD PHARMACY UKROPS PHARMACY FAMILY CARE PHARMACY NAVARRO DISCOUNT PHARMACY UNITED PHARMACY FAMILY PHARMACY NEIGHBORCARE VALLEY PHARMACY FARM FRESH PHARMACY OSCO DRUG VILLAGE PHARMACY FARMER JACK PHARMACY OSCO PHARMACY VONS PHARMACY FOOD CITY PHARMACY PAMIDA PHARMACY WALDBAUMS PHARMACY FOOD LION PHARMACY PATHMARK PHARMACY WALGREEN DRUG STORE FOOD WORLD PHARMACY PHARMACY EPRESS WAL-MART FRED MEYER PHARMACY PHARMERICA WEGMAN PHARMACY FREDS EPRESS PICK N SAVE PHARMACY WEIS PHARMACY FREDS PHARMACY PLAZA PHARMACY WHITE DRUG FREDS PRESS PRICE CHOPPER PHARMACY WINN DIIE PHARMACY FRUTH PHARMACY PRICE CUTTER PHARMACY 13

14 8. TREATMENT AUTHORIZATION FORMS Treatment Authorization is intended to help with providing prompt medical care for workplace injuries. The Treatment Authorization Form (found on the following page) should be sent with the injured employee at the time of the initial medical treatment. This authorization is only for the initial examination. Additional treatment will need to be authorized by contacting the Sentry Claim Representative handling the claim. 14

15 TREATMENT AUTHORIZATION FORM (Date of Report) To Doctor (Insert Name) Our Employee (Name of Injured) claims an injury while in our employment on (Date of Injury) Please provide medical attention and report condition to Sentry Insurance at once. If the injury is not the result of employment, this authorization shall apply only as a request for an examination and report at the expense of Sentry Claims Service. NOTICE TO DOCTOR (Name of Employer) ATTACH THIS AUTHORIZATION TO YOUR FIRST REPORT AND FORWARD OR FA PROMPTLY TO SENTRY CLAIMS SERVICE By: PO BO 8032 STEVENS POINT, WISCONSIN FA # Please make a copy of this form and provide to the injured employee. 15