MAKING IT EASY... TO GET WORKERS COMPENSATION PRESCRIPTIONS FILLED.

Transcription

1 Optum PO Box Tampa, FL MAKING IT EASY... TO GET WORKERS COMPENSATION PRESCRIPTIONS FILLED. Optum has been chosen to manage your workers compensation pharmacy benefits for your employer or their insurer. 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. Questions? Need Help? Most pharmacies, including Walgreens, our preferred provider, and all major chains, are included in the network. To find a network pharmacy call or visit tmesys.com. Attention Pharmacists: Enter RxBIN, RxPCN and GROUP. Member ID # format is the date of injury and SSN combined as follows: YYMMDD WORKERS COMPENSATION PRESCRIPTION DRUG PROGRAM CARRIER/TPA EMPLOYER INJURED WORKER NAME Please provide directly to Pharmacist SOCIAL SECURITY NUMBER DATE OF INJURY (YYMMDD) Tmesys is the designated PBM for this patient. Tmesys Pharmacy Help Desk NDC RxBIN or RxPCN CAL or GROUP Envoy Envoy Acct. # Notice to Cardholder: Present this card to the pharmacy to receive medication for your work-related injury. To locate a pharmacy: tmesys.com. 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 the Optum Workers Compensation and Auto No Fault division: PMSI, LLC, dba Optum Workers Compensation Services of Florida; Progressive Medical, LLC, dba Optum Workers Compensation Services of Ohio; Cypress Care, Inc. dba Optum Workers Compensation Services of Georgia; Healthcare Solutions, Inc., dba Optum Healthcare Solutions of Georgia; Settlement Solutions, LLC, dba Optum Settlement Solutions; Procura Management, Inc., dba Optum Managed Care Services; Modern Medical, dba Optum Workers Compensation Medical Services, collectively and individually referred as Optum. IMP FFWG

2 Optum PO Box Tampa, FL HACEMOS MÁS SENCILLO... EL ABASTECIMIENTO DE LAS RECETAS MÉDICAS DEL PROGRAMA DE COMPENSACIÓN POR ACCIDENTES LABORALES. Optum ha sido elegido para administrar los beneficios farmacéuticos de su programa de compensación por accidentes laborales para su empleador o su asegurador. Más adelante incluimos su tarjeta First Fill que le permitirá recibir las recetas médicas relacionadas con su lesión en su farmacia local. Llene esta tarjeta siguiendo las instrucciones que se indican a continuación. Empleado lesionado: Si necesita que se le abastezca su receta médica para una lesión o enfermedad relacionada con su trabajo, visite una farmacia de la red Optum Tmesys. Entregue esta tarjeta temporal al farmacéutico. El farmacéutico abastecerá su receta médica bajo costo o sin costo alguno. Si se acepta su reclamación del programa de compensación por accidentes laborales, recibirá una tarjeta permanente por correo. Use esa tarjeta para otras recetas médicas de lesiones o enfermedades relacionadas con su trabajo. Tiene alguna pregunta? Necesita ayuda? La mayoría de farmacias, incluyendo Walgreens, nuestro proveedor preferido, y todas las grandes cadenas de farmacias, forman parte de la red. Para encontrar una farmacia de la red, llame al o visite tmesys.com. Attention Pharmacists: Enter RxBIN, RxPCN and GROUP. Member ID # format is the date of injury and SSN combined as follows: YYMMDD WORKERS COMPENSATION PRESCRIPTION DRUG PROGRAM PORTADORA NOMBRE DEL TRABAJADOR LESIONADO Please provide directly to Pharmacist NUMERO DE SEGURO SOCIAL EMPLEADOR FECHA DE ALA LESION (AAMMDD) Aviso para el titular de la tarjeta: Presente esta tarjeta a la farmacia para recibir los medicamentos para la lesión relacionada con su trabajo. Para ubicar una farmacia, visite tmesys.com. Tmesys is the designated PBM for this patient. Tmesys Pharmacy Help Desk NDC Envoy RxBIN or RxPCN CAL or Envoy Acct. # GROUP NOTA: Esta tarjeta First Fill solo es válida para una lesión o enfermedad cubierta por su programa de compensación por accidentes laborales. Empleador: Inmediatamente después de recibir un aviso sobre una lesión, llene la información antes indicada y entregue este formulario al empleado. The following entities comprise the Optum Workers Compensation and Auto No Fault division: PMSI, LLC, dba Optum Workers Compensation Services of Florida; Progressive Medical, LLC, dba Optum Workers Compensation Services of Ohio; Cypress Care, Inc. dba Optum Workers Compensation Services of Georgia; Healthcare Solutions, Inc., dba Optum Healthcare Solutions of Georgia; Settlement Solutions, LLC, dba Optum Settlement Solutions; Procura Management, Inc., dba Optum Managed Care Services; Modern Medical, dba Optum Workers Compensation Medical Services, collectively and individually referred as Optum. IMP FFWG

3 RETURN-TO-WORK; A GREAT IDEA We at the AmTrust Group, are convinced that an employer who provides light, or restricted work for injured employees, enjoys numerous benefits. This is not just an opinion, it s something we see day in and day out. Consider: Unless an injured worker returns to the workplace within 60 days, chances of him/her ever returning drop dramatically. (resulting in a very expensive permanent disability situation.) After 6 months away from the workplace, only 50% chance of return. After 12 months, only a 10% chance of return. Some Return-to Work Benefits Include: Test of malingering potential. Injured employees who refuse light duty are more prone to being malingerers. Opportunity for employer to demonstrate true concern for workers well-being. Promotion of rehabilitation and recovery. Lower medical and rehabilitation costs. Productivity. Morale improvement for the injured worker. Ability for the employer to monitor the injured employee s recovery progress. Decrease of WC claims costs, with resultant downstream WC premium savings. (Notice we re not just talking about feel-good issues, but also hard dollars!) Some common misconceptions (and truths) about Return-to-Work / Light Duty: Misconception: We ve already got too many programs around here, and don t need any more paper. Truth: While it is true a written, planned program works best, in many cases a Light Duty program can be nothing more than a management understanding of the benefits and principles of Return-to-Work, how it works, and the commitment to just do it, when light-duty recommendations are made by WC physicians. Misconception: It will get me into an Americans With Disabilities (ADA) situation. Truth: Light-duty and ADA reasonable accommodation are two entirely separate issues. Generally, light duty is a temporary assignment, for a relatively short period. ADA accommodations are made for serious, permanent disabilities that impair major life activities. Misconception: I ll have to devise a whole new job each time an employee needs light duty. Truth: The vast majority of light-duty restrictions require accommodating only one or two factors, such as no lifting over 10 pounds, or the like. In many cases, if you break the jobs down into individual tasks, you ll see that only one or two tasks within the employee s normal job are affected, and can be handled in some other way. Misconception: Once an employee gets into a cushy light-duty job, s/he ll never leave it, and I ll be stuck with it. Truth: Light duty is always defined by, and monitored by the attending physician. An employee on light duty is periodically monitored by the physician for improvement, and is released for full-duty as soon as medically indicated. Misconception: We re a union company. Our union won t allow us to pay lower rates, or move employees between classifications, or between bargaining groups. Truth: Any Local that objects to a Return-to-Work program should be referred to its national body for guidance. Return to Work is universally recognized as a very positive influence on an injured worker (as well as benefiting the employer). Labor unions, whose major purpose for existence is the benefit of the workers they represent, should not only tolerate Return-to-Work programs, but enthusiastically promote, and assist in such programs implementation and operation. It is strongly suggested that management approach labor representatives to solicit their input, and assistance in making Return to Work a positive force in your workplace. Misconception: I might be willing to place a worker in a light-duty position, but I can t afford pay them their full pay, for the decreased productivity. Truth: Talk to your WC insuror s claims professional. In many cases, states WC plans provide for make-up pay to replace some, or all of the injured employees decreased earnings. The goal of getting them back to the workplace, and doing some productive work is that important!

4 DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS COMPENSATION REMEMBER: IT IS IMPORTANT TO TELL YOUR EMPLOYER ABOUT YOUR INJURY The name, address and telephone number of your employer s workers compensation insurance company, third-party administrator (TPA), or person handling workers compensation claims for your company, are shown below. Employer Name: Date Posted: IF INSURED: (Complete all applicable spaces) IF SOMEONE OTHER THAN INSURER IS HANDLING CLAIMS: (Complete all applicable spaces) Name of Insurance Company: Name of TPA (Claims administrator): Address: Address: Telephone Number: Telephone Number: Insurer Code: IF SELF-INSURED (Complete all applicable spaces) IF SOMEONE OTHER THAN SELF-INSURER IS HANDLING CLAIMS: (Complete all applicable spaces) Name of person handling claims at Name of TPA (Claims administrator): the self-insured: Address: Address: Telephone Number: Telephone Number: Insurer Code: Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers Compensation Act, 77 P.S , and may also be subject to criminal and civil penalties under 18 Pa. C.S.A (relating to insurance fraud). Employer Information Claims Information Services Hearing Impaired Services toll-free inside PA: toll-free inside PA TTY: ra-li-bwc-helpline@pa.gov local & outside PA: local & outside PA TTY: *500* Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-500 REV 01-15

5 PANEL ACKNOWLEDGEMENT FORM (PA ONLY) NOTICE TO ALL EMPLOYEES TRAINING CONFIRMATION PLEASE READ CAREFULLY The information below describes your duties if you are injured at work. IN CASE OF WORK-RELATED INJURY OR DISEASE 1. The employee has the duty to obtain treatment for work-related injuries and illnesses from one or more of the designated health care providers for ninety (90) days from the date of the first visit to a designated provider. 2. The employee has the right to have all reasonable medical/surgical services and supplies, orthopedic appliances, and prostheses including required training in their use, related to the injury, paid for by the employer. 3. The employee has the right, during the ninety (90) day period to switch from one health care provider on the list to another provider on the list, and that all of the treatment shall be paid for by the employer. 4. The employee has the right to seek treatment from a referral provider if the employee is referred to him by a designated provider and the employer shall pay for the treatment rendered by the referral provider. 5. The employee has the right to seek emergency medical treatment from any provider but that subsequent, non-emergency treatment shall be by a designated provider for the remainder of the ninety (90) day period. 6. The employee has the right to seek treatment or medical consultation from a non-designated provider during the ninety (90) day period, but that these services shall be at the employee s expense for the applicable ninety (90) day period. 7. Should invasive surgery for an employee be prescribed by a physician or other health care provider so designated by the employer, the employee shall be permitted to receive an additional opinion from any health care provider of the employee s own choice. If the additional opinion differs from the opinion provided by the physician or health care provider so designated by the employer, the employee shall determine which course of treatment to be followed provided that the second opinion provides a specific and detailed course of treatment. If the employee chooses to follow the procedures designated in the second opinion, such procedures shall be performed by one of the physicians or other health care provides so designated by the employer for a period of ninety (90) days from the date of the visit to the physician or other health care provider of the employee s own choice. 8. The employee has the right to seek treatment from any health care provider after the ninety (90) day period has ended, and that treatment shall be paid for by the employer if it is reasonable and necessary. After ninety (90) days from the date of the first treatment, the employee shall have the duty to notify the employer of treatment by a non-designated provider within five (5) days of the first visit to the provider. The employer shall not be required to pay for treatment or services rendered by a non-designated provider prior to receiving this notification, if such services are determined, through utilization review, to have been unreasonable or unnecessary. 9. Written notice to an employee of the employer s/employee s rights and duties will be provided at time of training/hire and immediately after the injury or as soon thereafter as possible under the circumstances of the injury. 10. An employee may not refuse to sign an acknowledgement in order to avoid any duties specified in this notice. I acknowledge that my employer has developed a list of at least six (6) panel providers. I understand that following a work-related injury or illness, I am required to visit one of the physicians or health care providers designated by my employer for the initial 90 days of treatment (Day 1 begins on the day of my first medical appointment). I understand that if I do not comply with this requirement, my employer will not be required to pay for any medical services I receive during this period. I also understand that after 90 days, I can treat with any other physician or provider of my choosing, provided I notify my employer within five (5) days of my first visit. If I fail to do so, my employer may be relieved from paying for these services if they are deemed to be unreasonable or unnecessary. My employer has informed me in writing of my rights and duties pertaining to the Pennsylvania Workers Compensation Act. My signature below acknowledges that I have been so informed and that I understand my rights and duties. Employee s Signature: Date: Witness s Signature:

6 REQUIREMENTS FOR EMPLOYER'S LIST OF HEALTH CARE PROVIDERS 1. There must be at least 6 health care providers on the list, but there may be more than 6 listed. 2. At least 3 of the health care providers on the list must be physicians. 3. No more than 4 of the health care providers on the list may be coordinated care organizations (CCOs). 4. The names, addresses, phone numbers and areas of medical specialities of all health care providers must be included on the list. 5. The health care providers on the list must be geographically accessible and must have specialities that are appropriate based on the anticipated work-related medical problems of the employees. 6. Your employer must specify on the list if any of the health care providers on the list are employed, owned or controlled by your employer or its workers' compensation insurance company. NOTE: Your employer's list of health care providers must meet all of the above requirements. If the list does not meet all of these requirements, you do not have to choose a provider from the list. Instead, you have the right to seek medical treatment with any health care provider of your choice. BUREAU OF WORKERS' COMPENSATION HELPLINE INFORMATION CENTER (long-distance calls inside PAl (717) (local and calls outside PAl UF-1841B4/97E

7 Pennsylvania Workers Compensation Information To all employees: The workers compensation law in Pennsylvania provides wage loss and medical benefits to employees who cannot work, or who need medical care, because of a workrelated injury. Benefits are required to be paid by your employer when self-insured, or through insurance provided by your employer. Your employer is required to post the name of the company responsible for paying workers compensation benefits at its primary place of business and at its sites of employment in a prominent and easily accessible place, including, without limitation, areas used for treatment of injured employees or for the administration of first aid. You should report immediately any injury or work-related illness to your employer. Your benefits could be delayed or denied if you do not notify your employer immediately. If your claim is denied by your employer, you have the right to request a hearing before a workers compensation judge. The Bureau of Workers Compensation cannot provide legal advice. However, you may contact the Bureau of Workers Compensation for additional general information at: Bureau of Workers Compensation 1171 South Cameron Street, Room 103 Harrisburg, PA Telephone number within Pennsylvania: Telephone number outside of this Commonwealth: TTY (for hearing and speech impaired only) PA Keyword: workers comp. I,, employee of (employer), certify that I received, read, and understood the information provided above on my date of hire (date). If applicable: I,, employee of (employer), certify that I received, read, and understood the above information on (the date of work-related injury or disease). New 8/07

8 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA (TOLL FREE) TTY (TOLL FREE) EMPLOYEE FIRST NAME EMPLOYER S REPORT OF OCCUPATIONAL INJURY OR DISEASE EMPLOYEE SOCIAL SECURITY NUMBER DATE OF INJURY EMPLOYEE LAST NAME STREET ADDRESS CITY STATE ZIP CODE - COUNTY PHONE NUMBER EMPLOYEE: NUMBER OF DEPENDENTS DATE OF BIRTH MALE MARRIED FEMALE SINGLE OCCUPATION OR JOB TITLE NCCI CLASS CODE (IF KNOWN) EMPLOYMENT STATUS FT = Full-time SL = Seasonal PT = Part-time VO = Volunteer ZZ = Other EMPLOYER STREET ADDRESS CITY STATE ZIP CODE - SIC CODE EMPLOYER FEIN PHONE NUMBER - COUNTY NAICS CODE FULL PAY FOR DAY OF INJURY? TIME EMPLOYEE BEGAN WORK TIME OF OCCURRENCE YES NO AM : : PM AM PM LAST DAY WORKED DATE DISABILITY BEGAN DATE EMPLOYER NOTIFIED DATE RETURNED TO WORK DATE OF HIRE CONTACT FIRST NAME CONTACT PHONE NUMBER CONTACT LAST NAME NOTICE: Report should be clearly completed, (preferably typed) and original mailed to the Bureau at the address in the upper left corner and a copy to employee and insurer. LIBC-344 REV 1-01 (OVER)

9 LIBC 344 TYPE OF INJURY CODE PART OF BODY AFFECTED CODE CAUSE OF INJURY CODE (ENTER CODES, IF KNOWN) TYPE OF INJURY OR ILLNESS PARTS OF BODY AFFECTED CAUSE OF INJURY DID INJURY OR ILLNESS OCCUR IF OUT OF STATE, SPECIFY WERE SAFEGUARDS OR SAFETY WERE SAFEGUARDS OR SAFETY ON EMPLOYER S PREMISES? STATE OF INJURY EQUIPMENT PROVIDED? EQUIPMENT USED? YES YES YES NO NO NO ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES DIRECTLY RESPONSIBLE. IF FATAL, GIVE DATE OF DEATH PHYSICIAN/HEALTH CARE PROVIDER FIRST NAME: LAST NAME: STREET CITY STATE ZIP HOSPITAL NAME: STREET CITY STATE ZIP POLICY/SELF INSURED NUMBER: INITIAL TREATMENT: NO MEDICAL TREATMENT MINOR BY EMPLOYEE CLINIC / HOSPITAL PANEL PHYSICIAN EMPLOYEE PHYSICIAN EMERGENCY CARE HOSPITALIZED MORE THAN 24 HOURS POLICY PERIOD FROM: POLICY PERIOD TO: WITNESS FIRST NAME WITNESS PHONE NUMBER WITNESS LAST NAME PERSON COMPLETING THIS FORM: NAME: INSURANCE CARRIER OR THIRD PARTY ADMINISTRATOR (IF SELF-INSURED) NAME: TITLE: STREET PHONE: CITY STATE ZIP DATE PREPARED BUREAU CODE: FEIN: Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165.