WC Procedures 1172006

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WC Procedures 1172006 Powered By Docstoc
					              Division of                      Section: 15-A                                                   Page: 1 of 4
            Human Resources                    Safety & Health
         Department of Environment             Incident and Workers’ Compensation Processes
            & Natural Resources                Reference:
                                               Workers’ Compensation Manual; OSP Manual, Section 6;
                                               WC Third Party Administrator (TPA) Management Services
                                               Publications, NCGS 97, NC DENR Safety Manual
                SOP Manual                     Issued Date:                    Revision Date:
                                               11/07/01                         1/17/2006, 2/5/2007

    PURPOSE: To provide clarification and to identify areas of responsibility for the NCDENR
    Workers’ Compensation Claims process.

Order of       Responsible        Action/Task
Steps for      Party
                                                             MEDICAL TREATMENT
                                                                   Day of the Accident/Injury
1              Employee               Report accident/injury to Supervisor/Management immediately.
2              Supervisor/            Get employee directly to the DENR Preferred Provider Facility.
               Management               Provide a brief description of the nature of the injury and how it
                                        Tell them that this is a Workers’ Compensation injury and give them
                                            the billing address from the Workers’ Compensation Medical
                                            Authorization form.
                                      Notify Division Workers’ Compensation Coordinator and Division Safety
                                       Officer/Safety Consultant of incident within 1 day of injury.
                                      First Aid Only-provide treatment consistent with training and experience.
                                       Complete a Form 19, (Employer’s Report of Employee’s Injury or
                                       Occupational Disease to the Industrial Commission) as noted below.
                                       Denote on Form 19 as “first aid only”, list "MRO" in the upper left corner
                                       of the Form 19, or list injury on the Division First Aid report.
                                      Life threatening or serious injury; contact EMS or if feasible, take to local
                                       emergency room.
                                      Provide Form Emp-1 and LeaveOp form (Employee Statement and Leave
                                       Options to employee) (Required)
                                      Complete Form 19 – (Employer’s Report of Employee’s Injury or
                                       Occupational Disease to the Industrial Commission) – must be signed by
                                       immediate supervisor. (NOTE: The current Form 19 includes the OSHA
                                       301 section at the bottom.) Provide employee a front & back copy of the
                                       completed form 19. (No later than 24 hours)
                                      Prepare a Workers’ Compensation Medical Authorization Form and give
                                       the employee two (2) copies.
                                      Prepare a Return To Work form and give to employee for physician to
                                      Have employee read and ask them to sign the WC Release of Information
                                      Provide employee with a NC Industrial Commission Form 18.
                                       Send all completed forms to Division Workers’ Comp Coordinator.
                                  NOTE: Although not part of the WC process, ensure that the injury is recorded on the form 300
                                  Log and Summary of Occupational Injuries and Illnesses, where applicable.
Order of    Responsible     Action/Task
Steps for   Party
3           Division          Send original Form 19 to DENR HR Workers’ Comp Administrator within
            Worker’s Comp   1 day. If form not fully complete, Fax a copy to DENR HR WC Administrator
            Coordinator     (919) 715-4515 with the original to follow.
                              Send all completed forms to DENR HR Workers’ Comp Administrator
4           DENR HR           Notify WC Third Party Administrator (TPA) of any urgent Claims
            Workers’ Comp     Coordinate with Divisions on items missing from submitted Form 19
            Administrator     Determine acceptance/denial of liability for submitted claims and make
                            recommendation to Safety Director on in-house retention or TPA involvement
                              Mail completed Form 19’s to WC Third Party Administrator (TPA)
5           Employee         Give the attending Physician a copy of the Workers’ Compensation
                                Medical Authorization/Return To Work form for billing purposes.
                             Ask that he/she complete it and return it to you before you leave the
                                Physician’s office.
                             If prescription medication is required to treat your injury, give the other
                                copy of the Workers’ Compensation Medical Authorization to the
                                Pharmacist. (Failure to do so could result in out-of-pocket cost to employee that
                                can only be reimbursed by submitting all Pharmacy receipts on Form 25P, which
                                must be obtained from your Division Workers’ Compensation Coordinator or
                               Complete the following forms and return to your Supervisor/Management.
                                  Employee Statement and Leave Option forms. ( Form Emp-1 and
                                      LeaveOp form )(Required)
                                  WC Release of Information form.
                                  Form 25P-Itemized Statement of Charges for Drugs (if applicable)
6           Supervisor/      Utilize Incident Investigation process to conduct an incident investigation
            Management          and complete the following forms:
                                  DENR Incident Investigation Report. A recommendation for
                                      Corrective Action of the incident cause must be included in this report.
                                      Attach signed witness statements to form Emp-1.
7           Division         Provide Form 25P (prescription expenses, if applicable) to DENR HR.
            Workers’ Comp    Provide a completed copy of Incident Investigation Report to Division
            Coordinator          Safety Officer/Safety Consultant
                                 Maintain a Workers’ Compensation file for each individual injured. (Not
                                 part of the employee Personnel File)
                                       Retain the complete form five (5) years following closure of
                                       Retired files are sent to DENR HR.
                                 Create a seven (7) day suspense file to follow-up with supervisor.
                                 Keep a chronological list of itemized bills and events in each individual’s
                                 WC claim folder.
                            If employee is going to be out more than seven (7) calendar days, notify
                            Division HRM and DENR HR Workers’ Comp Administrator in writing for
                            payroll, STD or LTD purposes. Provide option the employee selected on their
                            Employee Statement and Leave Options form.
8           Supervisor/          Locate and offer RTW duties, consistent with physician’s parameters.
            Management           Make weekly contact with the injured employee.
                                 Occasionally attend follow-up medical visits with the employee to ensure
                                 the physician/Physical Therapist is aware of DENR willingness to use
                                 transitional duty.
9           Division HRM         Assist supervisors/managers in Return to Work (RTW) situations requiring
                                 permanent transfers of injured employees to another position because of
                                 the injury.
Order of    Responsible       Action/Task
Steps for   Party
10          DENR HR WC            Provide completed forms to WC Third Party Administrator (TPA).
            Administrator         Maintain a copy of all forms and paperwork relating to employee injury in
                                  Employee Workers’ Compensation file for 5 years after closure.
                                  Reconcile bills from WC Third Party Administrator (TPA).
                                  Coordinate with Division WC coordinator, Medical and Pharmacy
                                  providers and WC Third Party Administrator (TPA) on claims resolutions
                                  including RTW.
                                  Apprise Safety Director of ongoing claims status and RTW issues.
11          Employee              Provide Immediate Supervisor with completed Return to Work form.
12          Supervisor            Notify Division Workers’ Comp Coordinator of employee’s effective
                                  Return to Work date.
13          Division WC           Notify Division HRM of Return to Work and any restrictions.
            Coordinator           Send a copy of notification of return to work to DENR HR Workers’
                                  Comp Administrator.
14          WC Third Party        Maintain file on employee/accident/Workers’ Comp claim.
            Administrator         Reimburse employee for all charges for medications submitted on Form
            (TPA).                25P.
                                  Submit Form 19 to NC Industrial Commission.
                                  Provide appropriate employee related forms to employee as required by
                                  law or contract.
                                  Review forms; first approval/denial of claims for compliance and
                                  recognition of fraud or abuse.
                                  Responsible for communicating with DENR Personnel, Staff &
                                  Professionals prior to: mediation, assigning rehabilitative services/nurses,
                                  meeting/negotiating with attorneys and investigations.
                                  Coordinate with DENR staff, injured employee and Medical providers, and
                                  Rehab Specialists for claims resolution.
                                  Request and schedule mediations and hearings upon approval by DENR
                                  Liaison for clincher agreement. (Requires DENR written approval on
                                  clincher form prior to offer.) Coordinate clinchers with DENR Safety
                                  Director and Workers’ Comp Administrator. (DENR HR Workers’ Comp
                                  Administrator will coordinate with Division).
15          Division Safety       Contact Division Director and DENR Safety Risk Management regarding
            Officer/Safety        serious injuries and fatalities within 2 hours.
            Consultant            Work with Division to implement corrective actions. Work with
                                  supervisor towards Return to Work for injured employees.
16          DENR Safety           Review submitted DENR Incident Reports on sporadic basis to determine
            Director              any program corrections.
                                  Initial review and approval of all clincher agreements.
                                  Provide advice and options to Division Directors on WC resolution.

Order of           Responsible     Action/Task
Steps for          Party
                                               DEATH OF EMPLOYEE (Occupational)
1                  Supervisor/        Notify local emergency service organization, Division Safety Officer,
                   Management          Safety Consultant, Division Director and Division HRM within 1 hour.
                                      Prepare Form 19, and DENR Incident Investigation Report.
                                      Send to Division Workers’ Comp Coordinator.
                                      Record injury on the form 300 Log and Summary of Occupational Injuries
                                       and Illnesses if applicable.
2                  Division            Notify Secretary’s Office, DENR PIO and DENR Safety Director.
                   Director            Determine proper person to notify family. (Bereavement Team)
                                       Contact WC Administrator to discuss State’s memorial process.
3                  Secretary’s         Notify Governor’s Office
4                  DENR Safety         Provide consultative assistance to Division on notification process to
                   Director            OSHA and OSP regarding occupational fatalities. (No later than 8 hours)
5                  Division WC         Process forms as outlined under Emergency Treatment.
                   Coordinator         Coordinate funeral expense billing under Workers’ Compensation
                                       Notify DENR WC Administrator of funeral arrangements and contacts
6                  DENR HR WC          For accepted death claim, coordinate with Division HRM and TPA to
                   Administrator       ensure direct bill to DENR TPA for employer portion of funeral home
                                       expense. Obtain and coordinate any necessary documentation where
                                       known to resolve claim.
7                  Division HRM        Prepare PMSEP, PD135 and timesheet.
                                       See Separation Checklist in SOP Section 13-F.
                                       Assist family with making request for benefits.


    Links updated 3/6/2006