The following state forms have been included in your claims kit packet:

Transcription

1 RE: Workers Compensation Claims Kit Dear Policyholder: Welcome to Tower Group Companies Workers Compensation Insurance Program. Although we hope that your company never has to experience 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 Nebraska statemandated forms, and a step-by-step process to follow in case 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 Chicago, Illinois. Once reported, a claims representative will contact you to get additional information about the injured employee and to answer any questions that you might have regarding the Nebraska workers compensation process. The following state forms have been included in your claims kit packet: 1. Nebraska Workers Compensation Court First Report of Alleged Occupational Injury or Illness- NWCC Form 1 (rev. 11/20006) - This form must be completed when an employee reports an injury or illness. Please complete the form with as much available information as possible. 2. Nebraska Workers Compensation Court Subsequent Report- NWCC Form 4 (rev. 06/20006) - This form must be completed after the First Report of Alleged Occupational Injury or Illness. 3. Nebraska Employee s Choice or Change of Doctor Form- NWCC Form 50 (rev. 01/1997) - English/Spanish- The employer must give this form to the injured worker as soon as possible after an injury. This form contains information about the injured worker rights to choose a doctor to treat him/her after a work related injury. 4. Wage Statement- Please complete and send a copy of employees Wage Statement to Tower Group Companies at the time of injury. 5. 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 TGC (08/10)

2 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 Nebraska Workers Compensation Court First Report of Alleged Occupational Injury or Illness- NWCC Form 1 (rev. 11/20006)- and submit the form via one of the following: the completed form to wcreportaloss@twrgrp.com. This is the preferred method of reporting an injury. Fax to Tower Group Companies at Call the Tower Group Companies Claims office at By contacting your broker directly and providing the appropriate first report information. For injuries occurring after normal business hours, please call 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

3 Nebraska Workers Compensation Court First Report of Alleged Occupational Injury or Illness Employer NWCC Form 1 Revised 11/2006 Employer FEIN SIC Code Report Purpose OSHA Log Case # Employer Name(s) Insured Name (If different from employer name) Address City State Zip Code Phone Carrier FEIN Insured Address (If different) Insurance Carrier Administrator FEIN Location Name Claim Administrator (Name, address & phone number) Address City State Zip Code Phone Policy Number Policy Period: From To Self Insured Check if Appropriate Claim Administrator Claim # Jurisdiction Claim # Insurance Carrier/Self-Insured Code # Insured Report # Jurisdiction Name (Last, First, Middle) Address Employee Full Pay for DOI Yes No Salary Continued Yes Number or Dependents No Number of Days Worked Per Week Occupational Job Title Sex Male Female City State Zip Code Phone Date of Birth Social Security Number Date Hired Marital Status Married Separated Unmarried Unknown Occurrence/Treatment Wage $ Occupational Code Hourly Daily NCCI Class Code Weekly Date Employee Began Bi-Weekly Work-Related Duties Monthly Employment Status FT PT Other Date of Injury/Illness Time Employee Began Work0 Time of Occurrence Last Work Date AM AM PM (Cannot be determined ) PM Where Did Injury/Illness Occur? County State Zip Did Injury/Illness Occur On Employer s Premises? Yes No Date Employer Notified Date Disability Began Date Returned to Work If Fatal, Give Date of Death Type of Injury/Illness (Briefly describe the nature of the injury or illness; e.g. lacerations to forearm) Nature of Injury Code Part of Body Affected (Indicate the part of the body affected by the injury/illness; e.g. right forearm, lowerback; and how it was affected) Part of Body Code How Injury/Illness Occurred (Describe activity and tools, materials, equipment the employee was using; how injury occurred) Cause of Injury Code Initial Treatment: No medical treatment First aid by employer Minor clinic/hospital Emergency Room Hospitalized overnight Hospitalized > 24 hours Future major medical/lost time Name of physician or other health care provider: Date Administrator Notified Form Preparer s Name, Title and Phone Date Prepared WC 8111j (11-06) Wolters Kluwer Financial Services Uniform Forms TM

4 General Instructions (Item Definitions) Items in bold are mandatory fields. First Report of Injury or Illness (FROI) without this information will be returned. Employer: Employer FEIN the employer/insured s Federal Employer s Identification Number. SIC Code Standard Identification Classification code which represents the nature of the employer's business. Report Purpose defines the specific purpose of the transaction. (examples: original=00; cancel=01; change=02; denial=04; correction=co). OSHA Log Case # the Log Case number required for reporting to OSHA. Employer Name include all business names/doing business as (dba) Address (including city, state, zip) the address of the employer s actual location where the employee was employed at the time of the injury. Phone phone number at the employer s facility. Insured Name (if different from employer) the named insured on the policy or the financially responsible self-insured employer. Insured Address (if different from employer) mailing address of the insured. Location a code defined by the insured/employer which is used to identify the employer s location. Insurance Carrier: Carrier FEIN carrier s Federal Employer s Identification Number. Administrator FEIN administrator s Federal Employer s Identification Number. Name the worker s compensation insurer, approved self insured, or intergovernmental risk management pool. Address address, city, state, zip code of insurer. Phone phone number of insurer. Claim Administrator (name, address, & phone) enter the name, address and phone number of the carrier, third party administrator, risk management pool, or self-insurer responsible for administering the claims, if different from carrier information. Policy # the number assigned to the contract/policy for that employer. Policy Period the effective and expiration dates of the contract/policy. Insurance Carrier/Self Insured Code # for insurance carriers, the number assigned by the Nat'l Assn. of Insurance Commissioners. For self-insured employers, the code number assigned by the court. Self Insured check if appropriate. Claim Administrator Claim # identifies a specific claim within a claim administrator s claims processing system. Jurisdiction Claim # number assigned by the court when the initial First Report is accepted. Insured Report # a number used by the insured to identify a specific claim. Jurisdiction the governing body or territory whose statutes apply (NE). Employee: Name give full name as shown on payroll (avoid initials if possible). Address address, city, state and zip code of employee. Date of Birth the date the injured worker was born. Social Security Number. Date Hired the date the injured worker began his/her employment with the employer. Full pay for DOI (date of injury) check one. Salary Continued check one. Number of Days Worked Per Week the number of the employee s regularly scheduled work days per week. Sex check one. Number of Dependents the number of dependents as defined by the Nebraska Workers' Compensation Act. Marital Status check one. Wage check one and state wage. Occupational Job Title the primary occupation of the claimant at the time of the accident. Occupational Code Standard Occupational Classification code used to identify the primary occupation of the employee at the time of the accident. NCCI Code The identifying number for an occupational classification. Date Employee Began Work-Related Duties date pertaining to employee s present occupation. Employment Status check one. Occurrence/Treatment: Date of Injury/Illness date on which the accident occurred (only one date of injury per form). Time Employee Began Work time employee began work for that date. Time of Occurrence time of day the injury occurred. Last Work Date the last paid work day prior to the initial date of disability. Where did Injury/Illness Occur complete county, state, and zip code. Did Injury/Illness Occur On Employer s Premises check one. Date Employer Notified the date that the injury was reported to a representative of the employer. Date Disability Began if not disabled answer none and skip questions. Date Returned to Work if injured has returned to work, complete this question. If Fatal, Give Date of Death, (date employee died as a result of a work-related injury.) Type of Injury/Illness describe the nature of injury. Nature of Injury Code the code which corresponds to the nature of the injury sustained by the employee. Part of Body Affected the part of the body to which the employee sustained injury. Part of Body Code the code which corresponds to the Part of the body to which the employee sustained injury. How Injury/Illness Occurred a free-form description of how the accident occurred and the resulting injuries. Cause of Injury Code the code that corresponds to the cause of injury Initial Treatment check one. Name of physician or other health care provider provide name of physician or other health care provider that treated employee for injury. Date Administrator Notified the date the claim administrator who is processing the claim received notice of the loss or occurrence. Form Preparer s Name, Title and Phone. Date Prepared date form was actually completed. Type or print neatly your response in ink. WC 8111j (11-06)

5 Nebraska Workers Compensation Court SUBSEQUENT REPORT NWCC FORM 4 REVISED 06/2006 EMPLOYEE NAME (Last, First, Middle) SOCIAL SECURITY NUMBER DATE OF INJURY REPORT EFFECTIVE DATE JURISDICTION DATE DISABILITY BEGAN PRE-EXISTING YES DATE OF REPRESENTATION DATE OF DEATH REPORT PURPOSE DISABILITY? NO RELEASED/ RETURNED RELEASED/ RTW WITHOUT RESTRICTIONS RELEASED RTW WITHOUT RESTRICTIONS AGENCY CLAIM NUMBER TO WORK (RTW) DATE RTW QUALIFIER RTW WITH RESTRICTIONS RELEASED RTW WITH RESTRICTIONS NUMBER OF DEPENDENTS DEATH DEPENDENT/ DATE OF MAXIMUM MEDICAL IMPROVEMENT PAYEE RELATIONSHIP WIDOW WIDOWER CHILDREN SIBLINGS PARENTS OTHER PERMANENT IMPAIRMENT BODY PART PERCENT BODY PART PERCENT BODY PART PERCENT EMPLOYER NAME FEIN INSURED REPORT NUMBER WAGE WAGE PERIOD WEEKLY BI-WEEKLY MONTHLY SEMI-MONTHLY PAYMENTS AVERAGE WEEKLY WAGE NUMBER OF DAYS WORKED PER WEEK SALARY CONTINUED IN LIEU OF COMP? YES NO PAID FROM PAID THROUGH # WEEKS # DAYS WEEKLY PAYMENT AMOUNT PAYMENT TYPE (MM/DD/YYYY) (MM/DD/YYYY) PAID PAID AMOUNT PAID TO DATE BENEFIT ADJUSTMENTS BENEFIT ADJUSTMENTS WEEKLY AMOUNT WEEKLY AMOUNT BENEFIT ADJUSTMENT TYPE (+ OR -) START DATE BENEFIT ADJUSTMENT TYPE (+ OR -) START DATE PAID-TO-DATE PAID-TO-DATE PAID TO DATE TYPE PAID TO DATE AMOUNT PAID TO DATE TYPE PAID TO DATE AMOUNT CLAIM ADMINISTRATION INSURER NAME FEIN CLAIM STATUS OPEN CLOSED REOPENED REOPENED/CLOSED THIRD PARTY ADMINISTRATOR NAME FEIN MEDICAL NOTIFICATION ONLY BECAME LOST TIME INDEMNITY BECAME MED ONLY TRANSFER CLAIM TYPE ONLY CLAIM ADMINISTRATOR CLAIM NUMBER AGREEMENT TO COMPENSATE WITHOUT LIABILITY WITH LIABILITY CLAIM ADMINISTRATOR ADDRESS PHONE # LATE REASON CITY STATE ZIP CODE DATE PREPARED FORM PREPARER S NAME PREPARER S PHONE

6 General Instructions Items in bold are mandatory fields. Subsequent Report of Injury (SROI) without this information will be returned. Item Definitions Employee Name the injured worker s legally recognized name. Social Security Number a number assigned by the Social Security Administration used to identify the employee. Date of Injury date on which the accident occurred (only one date of injury per form). Report Effective Date The date the payment which causes the form to be filed was made. Jurisdiction the governing body or territory whose statutes apply (NE). Date Disability Began the first day on which the employee originally lost time from work due to the occupational injury or disease or as otherwise defined by the jurisdiction. Pre-Existing Disability identifies the existence of a disability that existed prior to the injury. Date of Representation the date the claim administrator became aware that the claimant had secured legal representation. Date of Death the date the injured worker died. Report Purpose The MTC (maintenance type code) that corresponds to the reason the form is being filed. Released/Returned to Work (RTW) Date the date, following the most recent disability period, on which the employee actually returned to work, or was released to return to work, as identified by the return to work qualifier. Released/RTW Qualifier a code identifying the employee s return to work status, with or without physical restrictions. Agency Claim Number the number assigned by the Nebraska Workers Compensation Court to identify a specific claim. Number of Dependents the number of dependents as defined by the Nebraska Workers Compensation Act. Death Dependent/Payee Relationship the relationship of the dependent(s)/payee(s) to the deceased employee; to which relationship and benefit entitlement may be determined by an adjudicator s decision for distribution of the death benefit. Date of Maximum Medical Improvement the date after which further recovery from or lasting improvement to an injury or disease can no longer be anticipated based upon reasonable medical probability. Permanent Impairment Body Part Code a code referencing the part(s) of body permanently impaired. Permanent Impairment Percentage report the amount of part(s) of body or functional abnormality or loss which results from the injury and exists after the date of maximum medical improvements. Employer Name the name of the business entity of the insured where the employee was employed at the time of the injury. Employer FEIN the Federal Employer s Identification Number of the employer where the employee was employed at the time of the injury. Insured Report Number a number used by the insured to identify a specific claim. Wage Wage Period a code indicating the time period during which the wage was earned. Average Weekly Wage the average wage of the employee at the time of injury as calculated by the claims administrator or jurisdictional authority for the wage period. Number of Days Worked Per Week the number of the employee s regularly scheduled work days per week. Salary Continued In Lieu of Comp the employer has paid or is paying the employee s salary in lieu of compensation during an absence caused by a work-related injury. Payments Payment Type a code that identifies the payment being made. Payment From Date the first start date of a benefit period for which benefits were paid. Payment Through Date the last date of a benefit period for which benefits were paid. Payment Weeks Paid the number of whole weeks for a specific payment code. Payment Days Paid the number of days paid for a specific payment code. Payment Weekly Amount the net weekly rate for the payment code being paid. Payment Paid to Date the cumulative amount paid for the payment code being paid. Benefit Adjustments Benefit Adjustment Type DO NOT USE. Reserved for future use. Benefit Adjustment Weekly Amount DO NOT USE. Reserved for future use. Benefit Adjustment Start Date DO NOT USE. Reserved for future use. Paid-To-Date Paid to Date Type a code that identifies the type of paid to date/reduced earnings/recoveries made. Paid to Date Amount the amount defined by the paid to date/reduced earnings/recoveries code. Claim Administrator Insurer Name the name of the insurer or self insured assuming the employer s financial responsibility for workers compensation claim(s). Insurer FEIN insurer s Federal Employer s Identification Number. Third Party Administrator Name the name of the Third Party Administrator contracted to adjust the claim on behalf of the carrier or self insured. Third Party Administrator FEIN the Federal Employer s Identification Number of the third party administrator s independent adjuster, contracted to adjust the claim on behalf of the insurer or self insured. Claim Administrator Claim Number identifies a specific claim within a claim administrator s claims processing system. Claim Administrator Address the address, including zip code, and telephone number of the claim administrator. Form Preparer s Name the name of the person completing the form. Claim Status Claim Status a code representing the current status of the claim. Claim Type a code representing the current benefit classification of the claim as interpreted by the jurisdiction Agreement to Compensate a code used to identify the condition under which compensation benefits are being paid. Late Reason a code which identifies the reasons payment/report was not made within a jurisdiction s requirements. Date Prepared the date the form preparer completed the form. Preparer s Phone the phone number of the person completing the form. Type or print neatly your response in ink.

7 EMPLOYEE S CHOICE OR CHANGE OF DOCTOR FORM NOTICE TO EMPLOYER: GIVE THIS FORM TO THE INJURED WORKER AS SOON AS POSSIBLE AFTER EACH INJURY A: RIGHTS OF THE EMPLOYEE Under the Nebraska workers compensation laws, you may have the right to choose a doctor to treat you for your work related injury. You may choose a doctor who has treated you or an immediate family member before this injury happened. Immediate family members are your spouse, children, parents, stepchildren and stepparents. The doctor you choose must have records to show that past treatment was provided. Your employer may ask the person who was treated to give permission so the doctor can verify past treatment. If you want to choose your doctor, you must tell your employer the name of the doctor you choose. Do this as soon as possible after your employer gives you this notice and before getting any treatment unless it is emergency medical treatment. Once you tell your employer the name of the doctor, you may not change your choice unless your employer agrees or the Nebraska Workers Compensation Court orders a change. If you do not choose your doctor, your employer has the right to choose the doctor to treat you. The employer may also choose the doctor to treat you if you or your family member does not give permission so your employer can verify past treatment by the doctor you chose. You may choose a doctor if your claim is denied. You may also choose the doctor to do major surgery or for an amputation. You may use part B below to tell your employer the name of the doctor you choose. B: CHOICE OF DOCTOR o I choose the following doctor to treat me for this work related injury. I certify that this doctor has treated me or an immediate family member before the work related injury. o I do not have or I do not wish to choose a doctor who has treated me or an immediate family member. DOCTOR S NAME SIGNATURE OF EMPLOYEE DOCTOR S ADDRESS DATE C: USE TO CHANGE THE CHOICE MADE IN PART B, ABOVE I wish to change my choice of doctor or I wish to choose a doctor to treat me for my work related injury. I certify the doctor named below has treated me or an immediate family member before this work related injury. I understand that I cannot make this change unless my employer agrees or unless the Nebraska Workers Compensation Court orders a change. DOCTOR S NAME SIGNATURE OF EMPLOYEE DATE DOCTOR S ADDRESS SIGNATURE OF EMPLOYER DATE NWCC Form 50 (Rev. 1/97)

8 FORMA DE SELECCION O CAMBIO DE DOCTOR POR EL EMPLEADO. AVISO AL PATRON: DE ESTA FORMA AL TRABAJADOR LESIONADO, TAN PRONTO COMO SEA POSIBLE DESPUES DE CADA LESION A: DERECHOS DEL EMPLEADO Bajo la Ley de Compensación de Trabajadores en Nebraska, usted puede tener el derecho de escoger al doctor que lo trate para su lesión del trabajo. Usted puede escoger a un doctor que lo haya tratado a usted o a un miembro de su familia inmediata antes de que esta lesión haya ocurrido. Los miembros inmediatos de su familia son su esposa, sus hijos padres, hijastros y padrastros. El doctor que usted escoja debe tener archivos mostrando que tratamiento se le ha dado. Su patrón puede pedir a la persona tratada que de permiso al doctor para verificar el tratamiento pasado. Si usted quiere escoger doctor, usted debe decir a su patrón el nombre del doctor que elija. Haga esto tan pronto como sea posible, después de que su patrón le haya dado este aviso y antes de recibir tratamiento, a menos que este tratamiento médico en emergencia. Una vez que le diga a su patrón el nombre del doctor, no podrá cambiarlo a menos que su patrón acepte o si la Corte de Compensación a Trabajadores en Nebraska ordena el cambio. Si usted no escoje doctor, su patrón tendrá el derecho de elegir al doctor que lo trate a usted. El patrón también puede elegir el doctor que lo trate, si usted o el miembro de su familia no da permiso para que su patrón pueda verificar el tratamiento pasado por el doctor escogido por usted. Usted puede escoger un doctor si su reclamación es negada. Usted tambien puede escoger el doctor para hacer cirujía mayor o amputación. Usted puede usar la parte B., abajo, para decir a su patrón el nombre del doctor que ha escojido. B: SELECCION DE DOCTOR Yo escojo al doctor mencionado a continuación para que me trate por esta lesión del trabajo. Yo certifico que este doctor me ha tratado o ha tratado a miembros de mi familia antes de esta lesión del trabajo. Yo no tengo o no quiero escoger a un doctor que me haya tratado a mi o a miembros de mi familia inmediata. NOMBRE DEL DOCTOR FIRMA DEL EMPLEADO DOMICHILIO DEL DOCTOR FECHA C: USE PARA CAMBIAR LA SELECCION HECHA EN LA PARTE B, ARRIBA Yo quiero cambiar mi selección de doctor o yo quiero escoger a un doctor que me trate para mi lesión relacionada con el trabajo. Yo certifico que el doctor mencionado abajo, me ha tratado o ha tratado a miembros de mi inmediata familia antes de esta lesión en el trabajo. Yo entiendo que yo no puedo hacer este cambio a menos que mi patrón esté de acuerdo o a menos que la Corte de Compensación de Trabajadores en Nebraska ordene el cambio. NOMBRE DEL DOCTOR FIRMA DEL EMPLEADO FECHA DOMICILIO DEL DOCTOR FIRMA DEL PATRON FECHA NWCC Form 50 (Spanish 8/97)

9 W AGE S TATEMENT Employer: Employee: Please provide the 52 weeks of wages prior to the date of injury of Date employee ceased to work: Number of Hours employee is scheduled to work per week: Is employee paid by hour, day, week or month Date Hired Claim Number At what rate: Does Employee work Overtime Yes No If yes, is Overtime mandatory Yes No State the date and amount of any pay increases during the past 52 weeks Date Amount Date Amount Date Amount Date Amount Dates Incl of each Week Pd Hrs Wkd Regular Pay Overtime Pay Dates Incl of each Week Pd From To Yr From To Yr Hrs Wkd Regular Pay Overtime Pay SUBTOTAL SUBTOTAL GRAND TOTAL This is a correct statement of Employee s earnings as actually taken from Payroll Records Employer s Signature Title Date

10 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

11 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 x 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 Internet Access: For the standard national workers compensation network go to 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.

12 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 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.

13 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 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 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, Click on Pharmacy Locator and select how you would like to search for a nearby pharmacy. You may also call the helpdesk at 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 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

14 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 Necesitas ayuda en español? Llame al Prescription Card CARRIER / TPA EMPLOYER Attention Pharmacists: Call 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. INJURED WORKER NAME SOCIAL SECURITY NUMBER DATE OF INJURY Tmesys Pharmacy Help Desk 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 NDC Envoy RxBin or RxPCN CAL or Envoy Acct. # Pharmacist: 1. Call the Tmesys Pharmacy Help Desk at 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: Use our pharmacy locator online: PMSI, Inc. All rights reserved. C

15 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 Need help in English? Call Prescription Card PORTADORA EMPLEADOR Attention Pharmacists: Call 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. NOMBRE DEL TRABAJADOR LESIONADO NUMERO DE SEGURO SOCIAL FECHA DE LA LESIÓN Tmesys Pharmacy Help Desk 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 NDC Envoy RxBin or 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 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: Utilice nuestro localizador de farmacias en linea: PMSI, Inc. Todos los derechos reservados. C

16 Administered By: