Cannon Cochran Management Services, Inc.

Transcription

1 Cannon Cochran Management Services, Inc. Workers Compensation Forms and Internet Claims Reporting Presented by John D. Moore

2 WORKERS COMPENSATION - FIRST REPORT OF INJURY OR ILLNESS EMPLOYER (NAME & ADDRESS INCL ZIP) CARRIER/ADMINISTRATOR CLAIM NUMBER REPORT PURPOSE CODE Workers Compensation First Report of Injury or Illness C A R R I E R G E N E R A L C L A I M S A D M I N E M P L O Y E E JURISDICTION Arkansas INSURED REPORT NUMBER JURISDICTION CLAIM NUMBER EMPLOYER S LOCATION ADDRESS (IF DIFFERENT) LOCATION #: SIC CODE EMPLOYER FEIN PHONE # CARRIER (NAME, ADDRESS & PHONE NO) POLICY PERIOD CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO) TO CHECK IF APPROPRIATE Cannon Cochran Management Services, Inc N. University, Suite 767 Little Rock, AR SELF INSURANCE CARRIER FEIN POLICY/SELF-INSURED NUMBER ADMINISTRATOR FEIN AGENT NAME & CODE NUMBER NAME (LAST, FIRST, MIDDLE) DATE OF BIRTH SOCIAL SECURITY NUMBER DATE HIRED STATE OF HIRE ADDRESS (INCL ZIP) SEX MARITAL STATUS OCCUPATION/JOB TITLE UNMARRIED MALE SINGLE/DIVORCED EMPLOYMENT STATUS FEMALE MARRIED PHONE UNKNOWN # OF DEPENDENTS SEPARATED UNKNOWN NCCI CLASS CODE Form AR-1 W AG E RATE DAY MONTH # DAYS WORKED/WEEK FULL PAY FOR DAY OF INJURY? YES NO TIME EMPLOYEE BEGAN WORK PER: WEEK OTHER: hour DID SALARY CONTINUE? YES NO AM DATE OF INJURY/ILLNESS TIME OF OCCURRENCE AM LAST WORK DATE DATE EMPLOYER NOTIFIED PM PM CONTACT NAME/PHONE NUMBER TYPE OF INJURY/ILLNESS PART OF BODY AFFECTED DATE DISABILITY BEGAN NOW COMPLETED IN THE ice SYSTEM O C C U R R E N C E T R E A T M EN T O T H E R DID INJURY/ILLNESS EXPOSURE OCCUR ON EMPLOYER S PREMISES? TYPE OF INJURY/ILLNESS CODE PART OF BODY AFFECTED CODE YES NO DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED WORK PROCESS THE EMPLOYEE WAS ENGAGED IN 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 THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL CAUSE OF INJURY CODE DATE RETURN(ED) TO WORK IF FATAL, GIVE DATE OF DEATH WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? WERE THEY USED? PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS) HOSPITAL (NAME & ADDRESS) INITIAL TREATMENT WITNESSES (NAME & PHONE #) YES YES NO NO NO MEDICAL TREATMENT MINOR: BY EMPLOYER MINOR CLINIC/HOSP EMERGENCY CARE DATE ADMINISTRATOR NOTIFIED DATE PREPARED PREPARER S NAME & TITLE PHONE NUMBER HOSPITALIZED > 24 HRS FUTURE MAJOR MEDICAL/ LOST TIME ANTICIPATED

3 Arkansas Workers Compensation Commission Employee s Notice of Injury Form AR-N

4 Arkansas Workers Compensation Commission Supplemental Report Form AR-S

5 Arkansas Workers Compensation Commission Wage Statement Immediately Preceding Injury Date Form AR-W

6 Arkansas Workers Compensation Commission Instructions to Employers and Employees Form AR-P BE SURE TO UPDATE YOUR POLICY PERIOD LABEL

7 Arkansas Workers Compensation Commission Health Care Notice for Employees Under Managed Care Form AR-H

8 ASIT Members are Required to File Claims Via the Internet at Our Web Site: ice.ccmsi.com/ice ONECOOLNAME. ONEHOTSOLUTION. w w w. c c m s i. c o m / i c e Copyright 2002 Cannon Coc hran Management Servic es, Inc.

9 ice Login Screen Based on your Login ID and Password, you will have access to one of two options: 1) Claims/Reporting View or 2) Executive Portal View.

10 1) Claims/Reporting View Claims/Reporting View The claims/reporting view has access to various reporting functions and the ability to submit injury reports. ice Options Quick and easy access to ice options, websites and help desk.

11 Initial Claim Reports Creation of new initial report form Form Filler -Selection & completion of OSHA 301 -Selection and completion of FROI View, edit or delete initial report forms Search for initial reports

12 In-Progress Reports The following screen shot displays the 20 most recent In-Progress reports. The blue f icon gives you access to and complete an Inwork OSHA 301 and/or state first report of injury form. Delete Form You may select the red X to delete the Inwork report. The pencil icon allows you to recall the form and edit or make a copy.

13 Completed Initial Reports Completed Initial Report Forms The following screen shot displays the 20 most recent claim reports.

14 Completed Report Only Forms Completed Report Only Forms The following screen shot displays the 20 most recent report only reports.

15 Initial Reports View Search for a Report Search for a report by selecting the status, report type, date of loss, input date, last name, coverage or policy holder.

16 Create a New Report Initial Reports View By selecting the Create a New Report Button, you can then proceed to fill-out the on-line report form.

17 Completed Initial Reports Completed Initial Report Forms The following screen shot displays the 20 most recent claim reports.

18 Select the State Form Select your State Form or the OSHA 301 Form via CCMSI s Form Filler You can select the OSHA301 Incident Report (.pdf file) or other available forms after the initial report form has been completed. Select the OSHA 301 Form

19 State Form or OSHA s Form 301 Populated The data that was entered into the initial report form has been transferred. You may edit or add information to complete either form. Results for State Form Results for OSHA 301 Form

20 View or save State or OSHA s Form 301 You can generate either form by selecting the Save Data and Show Form button or save the data only for later editing.

21 Sample States First Report of Injury Form The completed form can be saved on your hard drive or printed. (Shown below are various state forms)

22 If you have any questions about ice, please call us at , ext or us at

23 Remember to Drug Test!

24 Post-Accident Drug Testing

25 Use This Form for Ordering Drug Testing Supplies Complete the Highlighted Areas and Fax to (901)

26 What s New?

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28 Core Values Do the Right Thing Respond with Care Serve with Passion Innovate Constantly Love to Learn Mission mymatrixx is committed to maximizing the potential of our customers, our employees, and our community by: Vision Improving the health and care of our patients Anticipating and soling our clients challenges Designing innovative and technology driven healthcare solutions Delivering timely, accurate and insightful information To deliver an unimaginably great customer experience

29 Straightforward Approach Fast. Simple. Effective. Results. Developed to serve the most complex situations, we provide our clients with a program to meet their needs. First Fill Form Individual Rx Card Mailed to Claimant Real-time Authorizations Mail Order Service and Compounding Pharmacy Options Available Customer Service 24/7/365 Comprehensive Clinical Programs

30 mymatrixx Network 62,000+ retail pharmacies in all 50 states and Puerto Rico with 767 in Arkansas. Including:

31 QUESTIONS

32 THANK YOU