pekin · pdf fileprescriptions information sheet to the employee reporting a ... provide your...

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Pekin Insurance | 2505 Court Street, Pekin, IL 61558 | www.pekininsurance.com

Pekin Insurance® sincerely thanks you for choosing us as your insurance carrier. As business owners too, we understand that keeping a business running smoothly takes effort. We have dedicated Loss Control and Workers Compensation professionals who are trained, knowledgeable, and ready to provide you with Beyond the expected® service.

ALL potential claims should be reported in a timely fashion. State fines and penalties can result if claims are not reported immediately following the incident. Also, cost containment measures are most effective when claims are reported promptly.

Pekin Insurance takes all claims seriously and proudly serves you with a 24-hour, 7-days a week Claim Call Center. Simply call 888-735-4611 when you need to file a claim.

This claims kit is designed to guide you through the process. Start with the Employee/Employer checklist as they outline the steps and other forms which need completion. Any time you have questions, please contact your claim representative.

Thank you again for choosing Pekin Insurance as your Commercial Insurance provider. Rest assured that when it comes to the claim service and coverage you deserve and you desire, Pekin Insurance will always strive to go Beyond the expected!®

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Updated 10/16

Pharmacy ProgramThe program provides discounts on workers compensation prescriptions submitted by your injured employee. The service gives preferred access to a national pharmacy network of over 65,000 retail pharmacies. Benefits include 18% lower costs per fill and 33% increase in generic drug utilization.• YOU provide the First Fill

Prescriptions Information Sheetto the employee reporting awork-related incident and injury.This form should be kept in asecure location.

• The injured employee completesthe form, then presents it with the prescription to a participatingpharmacy. The claim will beelectronically submitted by thepharmacy.

• After the claim is reported toPekin Insurance, a permanentplastic ID drug card will beissued directly to theemployee for all future workerscompensation prescriptions.

Medical Cost ContainmentPekin Insurance contracts with a medical bill review service which reviews all provider charges for appropriateness, usual and customary, and adherence to state mandatory fee schedules.

Further cost control is achieved through the use of a PPO Network. Providers in the network have agreed to discount their billings on treatment for your injured employees. Contact your Pekin Insurance claim specialist for a list of PPOs in your area.

Diagnostic Testing ProgramTo further contain cost, we have partnered with a vendor to save money on any diagnostic testing (CT scans, MRIs & EMGs) ordered by a treating doctor. To make this program successful, we ask you to encourage your employees to contact their Pekin Insurance claim specialist as soon as they know a test will be needed.

At that time, the vendor will be contacted. They will schedule the test, then notify the employee of the test location, date, and time. This process also expedites test results.

The “Did You Knows” of workers compensation medical expenses:

• In 2009 approximately $30billion was spent on workerscompensation medical expenses.

• 58% of all workers compensationexpenses are related to medicalexpenses.

• 15% to 19% of all medicalexpenses are related toprescription drugs (pharmacy).

• Pharmacy costs are increasingby 3% to 5% a year.

Pekin Insurance takes a proactive approach to controlling these medical expenses by participating in several medical cost containment programs. Use of the programs helps reduce your workers compensation costs. They are most effective when claims are reported immediately.

WORKERS COMPENSATION

COST CONTAINMENT

PROGRAMS

• Injured workers off work longer than six months have only a 50% chance of returning to their jobs; if time loss exceedsone year, there is a 90% chance they will never return to work.

• The good news is studies also show 80-90% of injured employees would rather return to work than collect disability.

Pekin Insurance has dedicated Loss Control and Workers Compensation professionals to assist employers with their return to work programs.

THE IMPORTANCE OF A RETURN

TO WORK PROGRAM

• Claims reported within 3 days have significantlylower average claim costs.

• 60% of workers off the job 14 days are alreadyexperiencing financial difficulty, which will mostlikely result in attorney involvement.

• The chances of litigation are 50% lower if theemployee understands their workers compensationbenefits. We encourage ongoing communicationfrom the employer and employer representative.

• The average workplace injury has quadrupled incost to $20,000 over the past 15 years.

THE IMPORTANCE OF PROMPT REPORTING

Claims can be reported to Pekin InsurancePhone – 800-322-0160, Fax – 309-346-9466

Handle the immediate medical needs of your injured employee.

Notify Pekin Insurance immediately of any injury that may be covered by your policy. Please remember to report incidents even when immediate medical treatment is not required.

You must submit a First Report of Injury and all medical documentation you have received. These documents should be sent directly to us or your local insurance agent.

Pekin Insurance Company 2505 Court Street Pekin, IL 61558

Phone: 800-322-0160 Fax: 309-346-9466

Have your injured employee’s supervisor complete the Supervisor Incident Report. Also, provide the name, address, and phone numbers of all witnesses to the incident.

Take out of use and keep all materials, machinery, or tools that may have contributed to the incident or caused the injury. Secure the name, address, and phone numbers of anyone you feel may be responsible for the incident. Pekin Insurance may be able to seek recovery from a responsible party.

Provide your injured employee with a copy of the First Fill Prescription Information Sheet. It is a temporary card that allows him or her to receive an initial supply of medication. A permanent card will be mailed to the employee once the claim is set up. Keep this form in a safe and secure location.

If the injured employee needs diagnostic treatment or durable medical equipment, contact us to make arrangements. These items include MRIs, CT scans, crutches, or braces.

Provide the injured employee with a copy of the Return to Work Form. The completed copy should be submitted directly to us by the doctor, employer, and/or employee.

Let us know if any light duty work is available to offer the employee once he or she is capable of returning to work.

Employer’s ClaimReporting Checklist


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If needed, seek immediate medical care for your injuries. Notify your employer of all incidents and injuries, even if you do not seek immediate medical care.

Request that your employer submit the First Report of Injury to us ASAP.

Secure and report the names of any witnesses to the incident. Also, identify any materials, machinery, or tools that you feel contributed to or caused your injury.

Request a copy of the Return to Work Form from your employer. It is your responsibility to ensure this is completed by your doctor, then returned to your employer or us after every visit.

Let your claim specialist know if your treatment has included or will include diagnostics or durable medical equipment such as MRIs, CT scans, crutches, or braces.

Provide your employer and us with the names and addresses of ALL medical providers who have treated you for the injuries.

Promptly complete and return all forms you receive from your claim specialist.

Your claim specialist may contact you to obtain additional information needed to complete the investigation of your claim. You may also contact your claim specialist with questions on the claim:

Pekin Insurance Company 2505 Court Street Pekin, IL 61558

Phone: 800-322-0160 Fax: 309-346-9466

This form is for the injured employee’s use.

Injured Worker’s ClaimReporting Checklist


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Injured worker’s name: Sex: ____Male ____Female

Social Security number: Date of Birth:

Address: Phone:

Date of Hire:

Job Title & Department:

Date of injury: Time of injury: Medical attention sought? YES NO

Name of facility or physician that provided treatment:

Witness to the incident:

Was or will a drug screen be completed? YES NO (please circle one)

Last Day Worked: Return to work date:

Scheduled work week at time of injury

Hours: Days per week: Start time: End time:

Injured worker’s normal/usual schedule

Hours: Days per week: Start time: End time:

Injured worker’s statement regarding the injury (list all circumstances and equipment involved)

Body Parts affected:

Type of injury:

The answers I have provided to the above questions are true to the best of my knowledge.

Injured worker’s signature: Date:

Supervisor signature: Date:

Supervisor Incident Report


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Injured Worker Name: ____________________ Social Security #:_____________________________

Date Of Injury:___________________________

Dear Injured Worker,

On your first visit, please give this notice to any pharmacy listed on this insert to expedite the processing of your approved Workers Compensation prescriptions, based on the established parameters by Pekin Insurance™. With the CorVel CorCareRx program, you do not need to complete any paperwork or claim forms. Simply present this CorVel First Fill Prescription Information Sheet to the pharmacy. You should not incur any costs or copayments at the pharmacy and will be allowed up to a 14 day supply of medications.

Dear Pharmacist,

Please use the Injured Worker’s SSN plus 8 digit Date of Injury (SSN+MMDDYYYY) as the 17-digit identification number when entering the following information to process an online claim to CorVel on behalf of Pekin Insurance injured workers:

BIN: 004336 PCN: ADV RxGrp: RXFFWC596

Pharmacies can contact CorVel Pharmacy Help Desk at (800) 563-8438 for assistance with claims processing. The Pharmacy Help Desk is available 24 hours a day, 7 days a week for your convenience.

There are 70,000 Participating Pharmacies in the CorVel Network. Below is a sample listing. Bi-Lo Pharmacy Fred’s Pharmacy Marsh Drugs Safeway Pharmacy Brooks Pharmacy Fry’s Pharmacy Medical Arts Pharmacy Sav-On Drug Store Brookshire Pharmacy Giant Eagle Pharmacy Medicap Pharmacy Schnuck’s Pharmacy City Market Pharmacy Happy Harry’s Medicine Shoppe Shop N’ Save CostCo Pharmacy H.E.B. Pharmacies Meijer Pharmacy Snyder’s Drug Store CVS Hy-Vee Pharmacy Minyard Pharmacy Target PharmacyDiscount Drug Mart Ingles Pharmacy NeighborCare Thrifty Drug Store Drug Mart Kash N’ Karry Osco Drug Tom Thumb Pharmacy Duane Reade Kerr Drug Pathmark Pharmacy United Drugs Fagan Pharmacy King Soopers Payless Pharmacy Von’s Pharmacy Family Drug K-Mart Pharmacy Price Choppers Wal-Mart Pharmacy Farmer Jack Kroger Pharmacy Publix Pharmacy Walgreens Pharmacy FarmFresh Longs Drug Store Raley’s Drug Center Wegman Pharmacy Food Town Marc’s Pharmacy Rite Aid Pharmacy Winn Dixie Pharmacy

PLEASE TAKE THIS INSERT TO THE PHARMACYInjured Worker’s First Fill Prescription Information Sheet


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Employer: Employee Name:

Address:

Job Title:

Completed by: Date completed:

Title of person completing form:

ACTIVITY NEVER OCCASIONALLY FREQUENTLY CONSTANTLY(0 hours) up to 3 hours per day 3 - 6 hours per day 6 - 8+ hours per day

SittingWalkingStandingBending (neck) Bending (waist SquattingClimbing (stairs/ladders) KneelingCrawlingTwisting (neck) Twisting (waist) Reaching (below shoulder level) Reaching (above shoulder level)

DOES THIS JOB REQUIRE LIFTING? (please circle) yes no How many times per day? Lifting (check appropriate box)

0-25lb 26-60lb 61lb and above

DOES THIS JOB REQUIRE CARRYING? (please circle) yes no How far? (estimate distance):

Carrying (check appropriate box) How many times per day? 0-25lb 26-60lb 61lb and above

DOES THIS JOB REQUIRE (please check if applicable): Driving cars Driving trucks Operating forklifts Walking on uneven ground Exposure to excessive noise Exposure to dust, gas, fumes, or chemicals

Working at heights Operation of foot controls or repetitive foot movement Use of special auditory equipment Working with bio-hazards such as blood borne

pathogens, sewage, or hospital waste

Job Duties


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Physician: Please fill out this form and fax to:

Employee: Completed form must be returned to your employer following each examination.

Employer: When received, route this form to Pekin Insurance.

Employer:Claim Number:

Date of Injury/Illness:

Date of Treatment:

Diagnosis AND Treatment Plan:

RETURN TO WORK: YES______ NO_______ FULL DUTY: __________________ (date)

MODIFIED DUTY: ___________________ (date) Check appropriate box below

Sedentary Work. Lifting 10lbs maximum and occasionally lifting and/or carrying such articles as dockets, ledgers, and small tools. Although a sedentary job is defined as one that involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met. Light Work. Lifting 20lbs maximum with frequent lifting and/or carrying of objects weighing up to 10lbs. Even though the weight lifted may be only a negligible amount, a job is in this category when it requires walking or standing to a significant degree or when it involves sitting most of the time with a degree of pushing and pulling of arm or leg controls. Light Medium Work. Lifting 30lbs maximum with frequent lifting and/or carrying of objects weighing up to 20 lbs. Medium Work. Lifting up to 50lbs maximum with frequent lifting and/or carrying of objects weighing up to 25 lbs. Light Heavy Work. Lifting up to 75lbs maximum with frequent lifting and/or carrying of objects weighing up to 40lbs. Heavy Work. Lifting up to 100lbs maximum with frequent lifting and/or carrying of objects weighing up to 50lbs.

EXPECTED DATE FOR MMI (maximum medical improvement):___________________________

NEXT APPOINTMENT:______________________________________________________________

MD SIGNATURE:___________________________________________________________________

Return to Work


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INSTRUCTIONS

General Instructions:

1. Please enter information into all of the areas of the First Report form, except the boxes at the top right corner of the form which is foroffice use only.

2. Enter all dates in MM/DD/YY format.

3. Please return completed form electronically by an approved EDI process.

4. For answers to questions, please call (317) 232-3808.

Definitions:

AGENT NAME AND CODE NUMBER: Enter the name of your insurance agent and his / her code number if known. This informationcan be found on your insurance policy.

ALL EQUIPMENT, MATERIALS OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR EXPOSURE OCCURRED: Listanything the employee was using, applying, handling or operating when the injury or exposure occurred. If the injury involves a fall, indicateany surfaces and / or objects the claimant fell on and where they fell from. Enter “NA” if no equipment, materials or chemicals were beingused (e.g. Acetylene cutting torch, metal plate, etc.).

AVG WG/WK: Claimant’s average weekly wage, calculated by totaling the latest 52 weeks of wages (including overtime, tips, etc.) anddividing by 52.

CLAIMS ADMINISTRATOR: Enter the name of the carrier, third-party administrator, state fund, or self-insured responsible for administeringthe claim.

CONTACT NAME / TELEPHONE NUMBER: Enter the name of the individual at the employer’s premises to be contacted for additionalinformation (i.e. Supervisor, HR Person, Nurse, etc.)

DATE DISABILITY BEGAN: The first day on which the claimant originally lost time from work due to the occupational injury or diseaseor as otherwised deigned by statute.

DEPARTMENT OR LOCATION WHERE ACCIDENT OR EXPOSURE OCCURRED: If the accident or exposure did not occur on theemployer’s premises, enter address or location. Be specific (e.g. Maintenance, Client’s Office, Cafeteria, etc.).

EMPLOYEE STATUS: Indicate the employee’s work status from the following choices: Full-time, Part-time, Apprentice Full-time, ApprenticePart-time, Volunteer, Seasonal Worker, Piece Worker, On-Strike, Disabled, Retired, Not Employed or Unknown (you may also abbreviatethe above as: (FT, PT, AFT, APT, VO, SW, PW, OS, DI, RE, NE, or UK).

HOW INJURY / ILLNESS OCCURRED: Describe the sequence of events leading to the injury or exposure (e.g. Worker stepped backto inspect work and slipped on some scrap metal. As worker fell, he brushed against the hot metal; Worker stepped to the edge of thescaffolding, lost balance and fell six feet to the concrete floor. The worker’s right wrist was broken in the fall).

NCCI CLASS CODE: A four-digit code classifying the occupation of the claimant.

OCCUPATION / JOB TITLE: Enter the primary occupation of the claimant at the time of the accident or exposure.

PART OF BODY AFFECTED: Indicate the part of body affected by the injury / illness (e.g. Right forearm, Low Back, etc.)

REPORT PURPOSE CODE: 00 = Original First Report of Injury; 02 = Updated or Amended First Report.

RTW DATE (Return to Work Date): Enter the date following the most recent disability period on which the employee returned to work.

SIC CODE: This is the code which represents the nature of the employer’s business which is contained in the Standard IndustrialClassification Manual published by the Federal Office of Management and Budget.

SPECIFIC ACTIVITY EMPLOYEE ENGAGED IN DURING ACCIDENT / EXPOSURE: Describe the specific activity the employee wasengaged in during the accident or exposure (e.g. Cutting metal plate for flooring, sanding ceiling woodwork in preparation for painting).

TYPE OF INJURY / ILLNESS: Briefly describe the nature of the injury or illness (e.g. Contusion, Laceration, Fracture, etc.)

WORK PROCESS THE EMPLOYEE WAS ENGAGED IN DURING ACCIDENT / EXPOSURE: Enter “NA” if employee was not engagedin a work process, such as if walking down the hallway (e.g. Building maintenance).

Cannot be determined

INDIANA WORKER’S COMPENSATIONFIRST REPORT OF EMPLOYEE INJURY, ILLNESSState Form 34401 (R10 / 1-02)

FOR WORKER’S COMPENSATION BOARD USE ONLYJurisdiction Jurisdiction claim number Process date

Please return completed form electronically by an approved EDI process. PLEASE TYPE or PRINT IN INKNOTE: Your Social Security number is being requested by this state agency in order to pursue its statutory responsibilities. Disclosure is voluntary and you will not be penalized for refusal.

EMPLOYEE INFORMATIONSocial Security number Date of birth Sex

Male Female UnknownName (last, first, middle) Marital status

Address (number and street, city, state, ZIP code)

Telephone number (include area Number of dependents

UnmarriedMarriedSeparatedUnknown

Occupation / Job title NCCI class code

Employee statusDate hired State of hire

Hrs / Day Days / Wk Avg Wg / WkPaid Day of InjurySalary Continued

Wage Per

$ HourYear

DayOther

Week Month

EMPLOYER INFORMATIONName of employer

Address of employer (number and street, city, state, ZIP code)

Employer ID#

Location number

Telephone number

Carrier / Administrator claim number

SIC code Insured report number

Employer’s location address (if different)

Report purpose code

Actual location of accident / exposure (if not on employer’s premises)

CARRIER / CLAIMS ADMINISTRATOR INFORMATIONName of claims administrator

Address of claims administrator (number and street, city, state, ZIP code)

Telephone number

Name of agent

Carrier federal ID number

Code number

Check if appropriate

Policy / Self-insured number

Policy periodInsurance CarrierThird Party Admin.

Self Insurance

From To

OCCURRENCE / TREATMENT INFORMATIONDate of Inj./ Exp.

Last work date

RTW date

Department or location where accident / exposure occurred

Specific activity engaged in during accident / exposure

How injury / exposure occurred. Describe the sequence of events and include any relevant objects or substances.

Name of physician / health care provider

Name of witness

Date prepared

Time of occurrence Date employer notified Type of injury / exposure Type code

Time workday began

Date of death

Date disability began Part of body

Telephone number Date administrator notified

Telephone numberName of preparer Title

Cause of injury code

Part code

Injury / Exposure occurredon employer’s premises?

YesNo

Name of contact Telephone number

All equipment, materials, or chemicals involved in accident

Work process employee engaged in during accident / exposure

INITIAL TREATMENTNo Medical TreatmentMinor: By EmployerMinor: Clinic / HospitalEmergency CareHospitalized > 24 HoursFuture Major Medical / LostTime Anticipated

AM PM

An employer’s failure to report an occupational injury or illness may result in a $50 fine (IC 22-3-4-13).

OSHA log number

Hospital or offsite treatment (name and address)

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