HomeMy WebLinkAbout2016 Workers Comp ProcedureJeanette Williams
From:
Cynthia Watson
Sent:
Friday, September 30, 2016 4:25 PM
To:
All Employees
Cc:
Cynthia Watson
Subject:
New Workers Compensation Program
Attachments:
Workers Compensation - PGCS Info & Forms.pdf
All Employees
The City of Sebastian has decided to change Workers Compensation Carriers. The new carrier effective October 1, 2016
is PGCS (Preferred Governmental Insurance Trust).
The PGCS Claim Services uses the Coventry Network Providers. I attached the list of Urgent Care providers. However,
please use Indian River Walk In Clinic or Indian River Health Services Inc. Do not go to the Emergency Room unless it is
necessary. Another feature is the Matrix Pharmacy program. The program will allow you to fill their initial prescriptions
without timely waits for authorization. You will need to give the pharmacy the Matrix phone number and a three day
supply of medication will be dispensed. The Matrix phone number is 877-804-4900. Matrix cards will be sent to you
with the initial Workers' Compensation package for continued use. The adjusters/nurses can update dispensing
information as needed so you can get your prescription filled with ease.
If you are ever injured, please complete the forms included in the above attachment.
If you have any questions, please do not hesitate to contact me.
Cindy
Managers
Please inform all employees who do not have email.
Thankyou.
Cynthia Watson, MPAIR, PHR
Assistant Administrative Services Director/HR
1225 Main Street
Sebastian, FL 32958
772-388-8222
cwatson 0citvofsebastla n.ora
C
Claim Services
ATTENTION
ALL EMPLOYEES
How to report Florida Worker's Compensation
Injuries Effective Immediately
PGCS has partnered with AmeriSys to provide excellent Care Providers (doctors and
hospitals) who are part of your employer's medical management program. Your
employer has selected the Coventry Network for treatment of work related injuries. If
you are injured on the job you will need to do the following...
1. Report your injury to your supervisorlmanager immediately.
2. You or your supervisor will call: 1-800-237-6617.
3. You will be asked to provide information such as:
a. Your full name
b. Your home address and phone number
c. Date of birth
d. Social Security number
e. Date, time, location and nature of injury
4. If you require treatment a Coventry Network Physician will be assigned for
you to see. An AmeriSys nurse may be assigned to interact with you, your
provider and employer.
Primary Care Phvsician for Emeroencv Treatment
Facility:
L.IM 115
Address: (.52 .9l5'17.
Vrzobea(,41 FL
Phone: 7U -aqq- /Oq,2.
Office Hours:
Facility: WNA4 -kllzrn� gms
Address: SDI (NEI , 5u iTe- 107
5G- iASTIA131 FL
Phone: '17a -,R� —/-/ZOO
Office Hours:
For additional information regarding your Workers' Compensation Claim call: PGCS at
1-800-237-6617
'PLEKSE- C,3o `VD u.V,6GV�T SRC t-%ACtLAt l
Do kV)� (,o TD F-P, l a iJ (.0 I IPIXA,ESS A-*)
P.O. Box 958456 • Lake Mary, FL 32795-8456 • Toll Free (800) 237-6617 • Phone (321) 832-1400 • Facsimile (321) 832-1448
Search Results oJ� , E fJT FAL � L M E-S Page 1 of 2
COV ENTRY
You Searched For We Found
Stale: FL ) p orl0en Found xMio your aevN le9un
Cori Motion Nrvar, FL
GIy. 5eYa3dad-Vera 9each
2q. 32956
n "o`MW' organded Nrru ni
NNe every ertMla ma4bman.n¢¢vak inklmaerL prouitivr"vdomueon ksupiea.. .. .. _, HeaMCareatn6 )93)G634 .. .., you nod in aavxknre began ddepntl a. proaiae.«ayou new amaedon. rcgar5lp
ew proutltruabp «b report bay, ngcueades in Ma pander fsong
A ee i
❑
Prouwr -_
Ptldncc -
phol
SpeatalN
Now Patlen.
UP
Update lnlarma6en .3.
❑
Indkn Rlm HealM Sod Mn
601 Merge; Way$to 107
)12.2M1200
Ur9<m Cam ginlc
V
Y
LYa:e la:oara�ai
Sebastian. FL 32956
❑
C.Spol Fapma Heatfun.
1820 Wan Ave Ste 110
)TT 25)- 32W
Ur gent OneGlnk
Y
uFlklnfq«slbn
Vero Bead. FL 32980
❑
ival heV Ugud ^wee CPMc
))) 37M St Sk C-101
)2E-))Oe690
lMgenlCua Gbk
Y
Y
111A:a1L IMa'n6lien
Vem BeatlA FL 32950
❑
InMan RiverYJ61A In Gink
85221MSt
19 St
V2-299.1092
yen
I.),,anal Clink
Y
Y
U pdek Ildo=rv:nn
Vera FL 32900
iJ
Iruq LLC Cta bkbn River NBA to C:krt
doo 21. St
))b 290.1092
Urgent Gra C9nk
Y
Y
Update inFo.rvdn
V. Bead, FL 32960
❑
Pan4•Wast U.yenl Carc
Veto Polmn Man tot
an "
P2-Z!"2w
U tCam Oink
ryen
Y
Y
0 plok Inla[:raann
Vero 9ead. FL
U: eM Cart IDt t
g
2050 e0N Ave Sk 6
))2S61-0DS
Urem den Oink
g
Y
U . InbmSxn
Vero Beaty. FL 329ti0
Adak
Vaxt Upchi OMMO16
Iwaadonx Plluup:Ix�ee
Fmpbyor «canier5elec. I. a¢epk Lerlcy Vbteare Comp lien.
n Me empbyer tag to provide i:aial bealnr+t or dare required by die ae don after mlueat by Me nryred an,*,.. the errpkyae may obtain 1.0 inital Ireabrent at the
axpens....
For Charming wMb Me FL MCA -Except For amnryenm situations. Intoned w«kun Ra.1 alive are Mard pdYden w60n Me Covmtry Imegtama Nunoom, In Flotwa
Oan Mined our,er unrel tank a Namu:k :guider in FL wNn age niwteuh:ika For a M,,W or Primary Cue Pvdiderer whin 60unintended for a umidaUk Me
nlryred.*..9 moveel approval tuna Me lm«to aak ae wlude Me mMah
In some InIU... Coventry nary hove a lnkp i n, prouder eyalable vAMk a WMedny itak. Iri Wker ""hire, am eonVaekd widn Covenryy, WI v.OW be
oonudered'out of NBlwdW for Me FL MCA The diner may approve needs. to Mese b«dedng alak prgaae. it 1) Mey erw.va We Coventry NaH.oh in Me forded,
https://www-sf.talispoint.com/talispoint/results.pl 9/30/2016
Search Results
Page 2 of 2
aisle, 3)a rCo "gpvbnq nala UtAs M M eM 3)%a mleape b Ne WsinW sus p vidw is nFLM pi Id s;nwrtwr,&g Ilw arsesaYq
WO ,sMM 1m is al ft umie. dwe andm Ise n svaltlsnaw FL MCAry ,.
IM:Wnsa+nm M�lYe w+ubaw^^✓YweWm^'M1 W au mroneou MV Mze. Pews sine N YngNaraM1xsNabdmnG re4feewY mal Yiverea�Y.CM^W
htln Caa Ypina"Canpnrpn.M niarneraprvaMYanvwiea�evaeylM m� qM MwmaemwnM1nN en fia�aw
MamYra Yagrav�.tr nit/GnYry�YMCan.M
https://www-sf.talispoint.com/talispoint/results.pl 9/30/2016
Claim Services
Medical Manaqement Information
Your Riqhts and Benefits:
• You will be provided with all reasonable and medically necessary medical care.
• A center/physician has been contracted close to your place of work to provide treatment in case
of an accident. This facility has been instructed to provide prompt service to the employees and
will ensure that treatment is appropriate to the injury,
• Except in the case of emergency, should you need arise for you to change the treatment provider
notify PGCS for assistance.
• If during the course of your treatment you desire to change your treating provider please contact
your adjuster and place in writing your desire for a change of provider. You can only change your
physician once during the course of your claim.
Your Responsibilities:
• You are responsible for maintaining all scheduled physician and provider appointments. Keeping
all of your appointments will ensure that you receive the full benefit of the medical care being
provided and will assist in your recovery. Please call PGCS with any problems or difficulties that
you experience. Our goal is to help you get better and we will work with you In order to achieve
that goal.
Provider Reimbursement:
• Reimbursement for medically related services will be made to authorized treating providers. If
you receive provider bills either at home or at work, they should be forwarded immediately to
PGCS for payment.
Pharmacv Reimbursement:
• PGCS will authorize certain pharmacies to bill us directly for prescriptions dispensed to you as
long as the prescription has been written by an authorized treating physician.
Medical Manaaement's Responsibilities:
• We will provide you with convenient access to medical care by contracting with a treatment
center/physician in a location close to you place of work. We will make sure that all medical
service provided to you are performed by licensed and qualified providers.
• We will coordinate your safe return to work by:
1) Working with your treating physician, obtaining all your physical capabilities from your treating
physician and forwarding that information to your supervisor.
2) Working with your supervisor to make sure they understand what you are able to do at work.
Grievance Procedures:
If you are not satisfied with the medical services you are receiving or with any of your medical
providers call PGCS to discuss your rights and benefits. Most issues can be resolved by
discussing them with your adjuster or their supervisor.
P.O. Box 958456 • Lake Mary, FL 32795-8456 • Toll Free (800) 237-6617 • Phone (321) 832-1400 • Facsimile (321) 832-1448
Claim Services
Work Flow to be Utilized to comply with Aaaressive Medical Care
Coordination and Claim Investigation:
The following outlines the steps involved to ensure compliance for
aggressive medical care coordination and investigation of the claim.
1. The injury occurs.
2. The injury is reported to the supervisor or designated workers'
compensation coordinator.
3. The supervisor or coordinator assists in channeling the injured
worker to a Point of Injury provider (physician, Urgent Care
Center or Hospital).
4. The supervisor or coordinator reports the injury to the Claims
Administrator. (PGCS)
5. PGCS then sets up the claim and it is given to the manager for
review and adjuster instructions.
6. The adjuster then makes a three point contact with the
employer, injured worker and physician's office.
7. The injured worker is seen by the provider and treatment plan
is established.
8. A nurse case manager maybe assigned if coordination of
medical care is needed.
9. Employee returns to work upon release from physician.
P.O. Box 958456 • Lake Mary, FL 32795-8456 • Toll Free (800) 237-6617 • Phone (321) 832-1400 • Facsimile (321) 832-1448
Claim Services
Qualitv Assurance
Goals and Obiectives
It is the intent of PGCS to provide a medical Management Arrangement that stresses
quality health care and return -to -work outcomes as the principle criteria for evaluating
quality of care rendered to the injured workers.
This comprehensive program is designed to:
• Establish a mechanism for monitoring health care medical management.
• Ensure that the health care services provided to the injured worker are of quality
and cost effective.
• Ensure that appropriate case direction is established at the onset of the injury
with focus on achieving optimum medical recovery as quickly as possible.
• Promote a cooperative, collaborative relationship among the injured work,
employer, medical provider and claims administrator to facilitate a timely return to
productive employment.
• Identify problem areas, establish priorities for investigation and recommended
plans for corrective action.
• Monitor grievances to asses corrective action needed and to assess results of
correction actions taken.
• Assess and monitor patient and customer satisfaction.
• Ensure timely initiation of treatment
• Assure a high quality of participating network providers.
• Comply with state mandated regulations and guidelines.
P.O. Box 958456 • Lake Mary, FL 32795-8456 • Toll Free (800) 237-6617 • Phone (321) 832-1400 • Facsimile (321) 832-1448
1k
Claim Services
Grievance Summary
PGCS Workers' Compensation
AmeriSys Grievance Summary
Your employer and Workers' compensation Carrier are concerned that you receive
appropriate medical treatment. It is important that you are aware of the following
information and procedures concerning Grievance Procedures.
• Your employer will direct you to a point of injury provider within the Coventry
Network.
• If you need to be referred to another provider or need emergency care, you may
contact PGCS for another provider. If the need arises for emergency care please
go to the nearest hospital.
• If you are dissatisfied or have questions concerning the medical care and
treatment provided by a Coventry provider, you may file a complaint (within one
year from the date of treatment or care in question), by contacting a PGCS
adjuster at 800-237-6617.
If you have any questions concerning the Coventry Network call 800-237-6617 or write:
PGCS / AmeriSys
P.O. Box 958456
Lake Mary, FL 32795
P.O. Box 958456 - Lake Mary, FL 32795-8456 • Toll Free (800) 237-6617 • Phone (321) 832-1400 • Facsimile (321) 832-1448
Carr,
Sen ryes
Grievan�
ce Form
P/eas ?i
resOfutio escribrievan
solutions YouWhichr
ccuOtedeb°eo o � Pleas w You �e Woull ce d rej ��t be/ow i�cl
Date of0ccurrer? 9 ievance ber that youh�aveSltuati �° Ma thisates and the s
\\ °Year from the IC
da er 0'
Please check n
P, o Box g 486 .
lake Mary. FL 32798.8g56
P. p P CS
Cake MaryxFC 8`,56
Toll Free (800) 237-6617 .
Phone f 3zjJ 832 1400 . Fecsi
/rile (329� 832 744g
Pr d
Claim Services
Answers to Freauentiv Asked Questions:
Q: Can I choose more than one Medical Care Coordinator?
A: Yes. This will be particularly useful with multi -location insured's.
Q: Can I get my current provider in the network?
A: We encourage you to use the existing network. If there is a business need to add a
provider, you may fax a request to PGCS 321-832-1448.
Q: If a hospital is listed in the Network, does this automatically include the occupation
clinics associated with the hospital?
A: No. Please check the Coventry list of providers to make sure the occupation clinic is
part of the network.
Q: Will a Claim number be assigned when calling in the First Notice of Injury:
A: Yes
Q: Is it necessary to mail/fax the First Notice of Injury to the State or other agencies
after reporting it via telephone?
A: No. PGCS will send copies of the First Notice of Injury or illness to the Employee,
Employer, and State
Q: Because I am calling the First Notice of Injury, must I still maintain the OSHA log?
A: No, PGCS can supply your OSHA 300 and OSHA 300A information if requested.
Q: How long will it take for the copy of the First Notice of Injury to be sent?
A: Within 24 hours of calling it in.
Q: Will my Network Medical Care Coordinator know that we have a drug -free workplace
program and do the appropriate testing?
A: No. You will need to notify the medical Care Coordinator that this needs to take
place. NOTE: It is important for you to establish a relationship with your Medical
Care Coordinator so he/she is aware of your individual needs. If you need help with
your clinic please contact Wendy Hall at Whall@PGCS-TPA.com for assistance.
Q: Can I send an injured worker directly to a specialist?
A: Yes. If approved by PGCS
Q: Where do I send my injured worker after hours?
A: If it is a life -threatening emergency, you should call 911 and utilize the nearest
hospital. Otherwise, direct the employee to the nearest -network urgent care center
or network hospital emergency room.
P.O. Box 958456 • Lake Mary, FL 32795-8456 • Toll Free (800) 237-6617 • Phone (321) 832-1400 • Facsimile (321) 832-1448
SUPERVISOR'S / EMPLOYEE INCIDENT/ACCIDENT INVESTIGATION REPORT FORM
Name of Employee:
Dept/Division ;
Time of Incident/Accident:
Date Garage Inspected Vehicle:
Location of Incident/Accident:
Date of Incident/Accident:
Supervisor:
Dept. Head:
Police Report #:
Vehicle ID#:
EmDlovee's Own Statement Describinz Incident / Accident (See Attached Sheet)
Supervisor's Report/Detail of Incident/Accident: Include sequence of events leading to Incident/Accident in detail.
In your opinion, why did the accident occur?
What should be done to prevent this Incident/Accident from happening again, and how will it improve operations?
Comments on prevention of future accidents
What Personal Protective Equipment (PPE) did the
Incident/Accident?
If the employee did not wear their PPE, please explain why?
employee wear at the time of the
Actions that may nrevent similar accidents in the future:
Daily Inspections Training Better Communications
Personal Protective Equipment Teamwork Engineering Control
Selection Better follow through with Employees
Please check below what is aoolicable:
I have reviewed the employee's statement and interviewed witnesses listed in the employee's report.
I have discussed this completed report with the employee before turning it into the Department Head.
I have not discussed this completed report with the employee before turning it into the Department Head for the
following reason(s):
I have informed the employee that this may be reviewed by the Accident Review Committee.
Signature of Supervisor Completing Form Date Signature of Dept. Head Date
PLEASE FORWARD TO ADMINISTRATIVEISERVICESWITHIN 24 HRS OF
INCIDENT/ACCIDENT
EMPLOYEE'S STATEMENT OF INCIDENT/ACCIDENT
Please Print
Name of Employee: Date of Incident/Accident:
Dept./Division: Supervisor:
Time of Incident/Accident: Dept. Head:
Date Garage Inspected Vehicle: Police Report #:
Location of Incident/Accident: Vehicle ID#:
Please Drovide below a statement in vour own words describine the Incident/Accident.
Signature of Employee Date
Date Form Completed and Reviewed with Supervisor
PLEASE FORWARD TO ADMINISTRATIVE SER DICES WITHIN 24 IIRS OF INCIDENT/ACCIDENT
S BAS T 7
HOME OF PELICAN ISLAND
PGCS WORKER'S COMPENSATION
CALL IN FORM
SS#
Home Address:
Male or Female: (circle) DOB:
Home Phone:
ORWI l
Name of employer: Citv of Sebastian
Employment address: 1225 Main Street, Sebastian, Florida 32958
Work Phone #:
Date of hire:
Rate/Pay:
Pay weekly: Biweekly
Person Reporting Injury:
Date of injury:
Type of injury:
Part of body affected:
Department:
Position:
Hours per week:
Time of injury:
Full/Part time: (circle)
Phone #:
am/pm
Paid for date of injury: yes/no (circle)
Agree with description of injury: yes / no / unknown (circle)
Employer authorized medical treatment: yes / no (circle)
Event description (explain how injury occurred):
Location description of injury: (ex: city hall, park, street location, etc.)
Address of location of injury:
Date & Time reported to employer:
Name of any witness to injury:
Did the injured employee already receive medical treatment, and if so
where?
Last date worked:
Has the injured worker returned to work: yes / no (circle)
Name of contact person at employer if additional information is required:
Email address: