Injury Reporting Procedure · If an employee experiences a work-related injury, complete the...

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Paychex Business Solutions, LLC Claim Packet – 8/2017

Injury Reporting Procedure

Your business is very important to us, and we're dedicated to providing you with the resources necessary to help you be as successful as possible. Paychex Business Solutions is partnered with Gallagher Bassett Claims

Management Services, Inc. to serve as our Third Party Administrator (TPA) for your Workers’ Compensation claims. The prepared outline and attached documents are to assist you in expediting the initial claim process once you are aware of a work-related injury.

Please take a few minutes to review the claims packet and locate the nearest approved medical facility prior to an injury occurring by using the national online search tool.

General website for provider searches in the Paychex network:

Visit: www.talispoint.com/cvty/gbppo

Click on search tabs to locate a provider, or create a Work Site Poster (Batch Tab)

Website for Paychex providers in the CA Medical Provider Network (MPN):

Visit: www.talispoint.com/cvty/gbmpn

Search for a provider or create a Work Site Poster (Batch Tab)

Locate a MPN doctor by calling GBMCS at 1-855-203-2845 At voice prompts, select Option 1

If an employee experiences a work-related injury, complete the applicable forms and report the claim within 24 hours. Claim reporting services are available 24 hours a day, 7 days a week. You can report a claim directly to Gallagher Bassett by choosing one of the three options:

1. Complete an “Accident/Injury Form” and then contact the dedicated claims reporting hotline at 1-855-397-0128, or

2. Email a completed “Accident/Injury Form” form to: [email protected], or 3. Fax a completed “Accident/Injury Form” form to 1-800-748-6159.

Have the employee complete the “Employee Statement” as soon as medically appropriate.

The following forms are in the claim packet. The appropriate party should complete each form listed and return it within 24 hours to Gallagher Bassett, regardless of whether the claim is an incident or report only claim, or if medical attention is required.

Forms Enclosed: Accident/Injury Form

Employee Statement

Medical Authorization Form

http://www.talispoint.com/cvty/gbppo

http://www.talispoint.com/cvty/gbmpn

mailto:[email protected]

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If the employee requires medical attention, select an initial authorized medical provider using the online network provider search tool (page 1). Once a provider is selected, the following material should either be sent with the employee to the facility for the initial appointment or faxed directly to the provider on behalf of the employee.

Forms Enclosed:

Letter to Treating Physician

Physical Demands Analysis

Please provide your employee the enclosed temporary pharmacy card along with the list of participating pharmacies in event a prescription is written at the initial appointment.

Forms Enclosed:

TMESYS / OPTUM - First Fill Temporary Pharmacy Card TMESYS / OPTUM - Retail Pharmacy Network

If the employee has a life threatening injury, call 911. If the injury is severe, send the employee for immediate treatment.

Do not delay treatment to complete paperwork in emergency situations.

As of January 1, 2015, federal OSHA updated the list of severe injuries that employers must report. If the accident or injury meets the following criteria you will also need to contact OSHA.

All work-related fatalities must be reported within 8 hours. All work-related inpatient hospitalizations, all amputations and all losses of an eye must

be reported within 24 hours.

You can report to OSHA by: Calling OSHA's free and confidential number at 1-800-321-OSHA (6742).

Calling your closest area office during normal business hours.

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cc to Gallagher Bassett Resolution Manager

Accident/Injury Form

Reporting Hotline 1-855-397-0128; Email [email protected] or Fax 1-800-748-6159

Client Name: _________________________________ Client Number: 741- ______________

Supervisor Name: ______________________________ Date/Time of Accident: _______________________

Employee’s Name: ___________________________ EE Job Title: _______________________________ (First Last)

Employee’s Home Address: ______________________ __________________________________________

Employee’s Phone #: ___________________________ Date of Hire: ____________ Age:

Social Security #: _______________________________ Sex: Marital Status:

Accident Location: _____________________________

Description of Accident:

Witness(es):

Detail any unsafe acts which may have caused or contributed to the alleged accident reported:

What actions will be taken, and by whom, in order to prevent the recurrence of this or similar incident?

Additional comments or information:

Completed by (print name and sign)

Printed Name: _____________________________________________________________________________

Signature: ________________________________________________________________________________

Date: ____________________________________________________________________________________


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Employee Statement Reporting Hotline 1-855-397-0128; Email [email protected] or Fax 1-800-748-6159

To be completed by the employee following an incident, accident, or injury Please complete this form using your own words:

Describe how the accident occurred:

Describe, in detail, all the parts of your body that were injured:

What caused you to have the injury/accident?

When did the injury/accident occur? Date:

Time:

Were you previously injured before the incident occurred?

Is there any other additional information about your injury/accident you’d like to give?

Do you require medical attention now? YES NO

If YES, give this report to your supervisor or manager and they must file a workers’ compensation claim. If medical aid is not required at this time, leave this report with your supervisor.

Note: If medical attention is not needed now for this injury but is necessary at a later date, you

understand that you MUST contact your supervisor, PRIOR TO seeking or obtaining treatment.

Completed by (print name and sign):

Printed Name: _______________________________________________________________________________

Signature: __________________________________________________________________________________

Date: ______________________________________________________________________________________


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MEDICAL AUTHORIZATION FORM

WORKER’S AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR WORKERS’ COMPENSATION PURPOSES (HIPAA COMPLIANT)

Reporting Hotline 1-855-397-0128; Email [email protected] or Fax 1-800-748-6159

INFORMATION Employee: ____________________________________ Date of Birth: __________________________________ Date of Injury: ___________________________________ SSN Address: __________________________________________________ Phone:

RELEASE I authorize the Health Care Provider (HCP) or any member or employee of its office or association who has examined or treated me, as well as any hospital or treatment facility in which I have been a patient, to disclose and release complete and legible copies of any and all information concerning my physical or psychiatric condition, care and treatment, to my employer,

, and/or its insurance carrier, , and/or their attorneys, and/or duly authorized representatives. Copies of all documentation released pursuant to this authorization shall be sent to the agency requesting the information and to me or my representative as listed above. I understand the following information will be released pursuant to a work-related/occupational injury or illness/workers’ compensation claim: medical reports; clinical notes; nurses’ notes; patient’s history of injury; subjective and objective complaints; x-rays; test results; interpretation of x-rays or other tests (including a copy of the report); diagnosis and prognosis; hospital bills; bills for services the HCP has rendered; payments received; and any other relevant and material information in the HCP’s possession. This Authorization also includes, if applicable, any hospital operational logs, emergency logs, tissues committee reports, psychiatric reports and records, physical therapy records, and all outpatient records. This release may also be used to request a Form Letter to HCP as approved by the Workers' Compensation Administration. I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law.

CONDITIONS I understand the purpose of this request is to determine the proper level of workers’ compensation benefits and may include information regarding any of the following: to determine my occupational injury or illness status; to determine my eligibility for workers’ compensation benefits; to determine my past, current and future medical status after occupational injury; to determine my current medical status and/or return-to-work capability.

Right to revoke: I understand I have the right to revoke this authorization at any time by notifying the company named in Paragraph 2. I understand that the revocation is only effective after it is received and logged by that company and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation. I further understand that my revocation of this authorization may affect my ability to receive occupational injury or workers’ compensation benefits governed by this revocation.

I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.

I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records. A photostatic or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided.

I understand I am entitled to a copy of this authorization and to any records provided hereunder.

Signature of Employee: __________________________________________________ Date:

Personal Representative Section: If a personal representative executes this form, that representative warrants that he or she has authorization to sign this form on the basis of (print detailed basis for representation): _______________________________________________________

Signature of Personal Representative: ______________________________________ Date:


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Send copy to initial treating provider

Letter to Treating Physician at Time of Injury

Date: __________________________________________ Employer Name:

Employer Contact: _____________________________ Title:

Employer Phone: ______________________________ Employer Email:

Employee Name: _____________________________

Social Security Number: _________________________ Date of Injury:

Location of Injury: _____________________________ Injured Body Part:

Description of Injury:

Our employee is presenting him/herself to you for medical treatment under the Workers’ Compensation protocol for a work-related injury. This will serve as our request and authorization for your facility to render the initial treatment for the above injured employee.

In the best interest of our employees, our company offers modified duty for all of employees injured on the job.

This employee has been instructed to return to work immediately after receiving treatment if medically able. Attached is the Physical Demands Analysis form outlining the physical requirements of the employee’s current position. Please review and provide any needed work restrictions that we can accommodate to promote the healing process and allow the employee to continue being productive in their work responsibilities.

Please note this letter does not confirm that this injury or diagnosis is covered by Workers’ Compensation insurance. Compensability will be determined when a Gallagher Bassett claims representative completes an investigation.

The reporting and billing information for our workers’ compensation insurance company is on the treatment authorization form.

Thank you,

Signature of Authorized Representative Printed Name Date

Submission of Medical Bills:

Please submit all medical reports within the time frame required by the applicable jurisdiction law. All claims for

treatment must be submitted to the address below on a HCFA 1500, UB92 or the

appropriate form required by the state:

Please mail all medical bills and accompanying medical reports to:

Gallagher Bassett Services, Inc.

P.O. BOX 2831

CLINTON, IA 52733-2831

All other correspondence is to be sent direct to the adjuster

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Send copy to initial treating provider

Physical Demands Analysis Please consider the following information while evaluating this patient’s work activities and ability to return to work

Employee: Job Title/Dept:

Employer: Date of Injury:

Employee’s schedule & activities:

ACTIVITY # HOURS/DAY # DAYS/WK Comments Total Work Sit Stand Walk Drive

How often in the workday does the employee have to lift/carry, push/pull:

WEIGHTS (lbs)

1-20

11-20

21-50

NEVER OCCASIONALLY (0-33%, 1-3 hours)

FREQUENTLY (34-66%, 4-6 hours)

CONSTANTLY (67-100%, 6-8 hours)

COMMENTS

51-100 >100

How often must the employee perform the following tasks? [N=Never, O=Occasionally, F= Frequently, C=Constantly]

Standing

Climbing

Balancing

Stooping Kneeling

N O F C Crouching

Crawling

Reaching

Handling

Feeling

N O F C Bending

Overhead Lifting

Work on Ladders

Fine Manipulation

Grasping

N O F C

N O F C N O F C N O F C



N O F C N O F C N O F C Environmental Conditions DESCRIPTION

Temperature Extremes Yes No

Noise Yes No

Inhalants Yes No

Chemicals Yes No

Overall Task Classification: Please check the degree of work this position requires an individual to perform.

Sedentary

Lifting 10 lbs maximum & occasionally lifting/carrying such articles as dockets, ledgers and small tools. Involves a certain amount of time sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking or standing is required only occasionally.

Light Lifting 20 lbs maximum with frequent lifting/carrying of objects weighing up to 10 lbs. Even though the weight lifted may be only a negligible amount, a job is in this category when it involves sitting most of the time.

Medium Lifting 50 lbs maximum with frequent lifting/carrying of objects weighing up to 25 lbs

Heavy Lifting 100 lbs maximum with frequent lifting/carrying of objects weighing up to 50 lbs

Very Heavy Lifting in excess of 100 lbs with frequent lifting/carrying of objects weighing 50 lbs or more

Transitional Duty Available? □ Yes □No

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