WORKERS COMPENSATION. Claims Kit

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WORKERS’ COMPENSATION

Claims Kit

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Dear Customer,

Thank you for choosing ProSight Specialty Insurance as your Workers’ Compensation Insurance carrier. We pride ourselves on providing excellent service and will do our very best to meet your Workers Compensation Claims needs.

ProSight Specialty Insurance writes our Workers’ Compensation policies through our New York Marine and General Insurance Company underwriting company, which is the name you will see listed on your policy.

In order to serve you more efficiently and to provide your organization with the best possible service; ProSight Specialty Insurance will now be directly handling your workers’ compensation claims. Please refer to the map to included with this packet for more information on your dedicated claims team.

Please make sure to include your Policy Number on all correspondence.

For your convenience, the following documents can be found inside your claims kit:

• Instructions on how to report a claim

• Claim Handling Map

• List of Claim office locations, mailing addresses, and claim contacts

• How to locate a Physician

• Pharmacy cards

• Links to your state’s Workers’ Compensation forms and Web Pages

Please do not hesitate to contact us should you have any questions or concerns. Workers’ Compensation Claims Department

ProSight Specialty Insurance 412 Mt. Kemble Avenue Morristown, NJ 07960

claimsinquiry@prosightspecialty.com

Phone: 800-774-2755 Fax: 855-657-3534

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Need to Report a Claim?

By e-mail:

claims@prosightspecialty.com

By phone:

(800)-774-2755

Press ‘1’ to report a claim

(Available anytime- days, nights & weekends)

Press ‘2’ to inquire about a claim

(Available 8:00am to 5:00pm EST)

By fax:

(800)-326-2864

By Mail:

ProSight Specialty Insurance Claims Department

412 Mt. Kemble Avenue

Suite 300C

Morristown, NJ 07960

Additional Instructions:

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EXPERIENCED PROFESSIONALS.

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Workers’ Compensation

Claim Handling

California Nevada Texas Florida Maine Pennsylvania Louisiana New York New Jersey Oregon Washington Idaho Ohio Kansas Arizona New Mexico Utah North Dakota South Dakota Oklahoma Montana Wyoming Colorado Iowa Minnesota Michigan Indiana Wisconsin Missouri Illinois Nebraska Massachusetts Rhode Island New Hampshire Vermont Connecticut Delaware Maryland Virginia West Virginia Kentucky Tennessee North Carolina South Carolina Georgia Alabama Mississippi Arkansas

ProSight Specialty Insurance

Gallagher Bassett Services

LWP Claims Solutions

Monopolistic

Alaska

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Mailing

Workers’ Compensation Claims Department

ProSight Specialty Insurance

412 Mt. Kemble Avenue

Morristown, NJ 07960

claimsinquiry@prosightspecialty.com

Phone: 800-774-2755

Fax: 855-657-3534

Claims Handling Offices |

ProSight Specialty Insurance

Contacts

WC Claims Manager: Melissa Kovacsy

mkovacsy@prosightspecialty.com

Lost Time Adjuster: Patrick Gano

pgano@prosightspecialty.com

Medical Only Adjuster: Melinda Bullock

mbullock@prosightspecialty.com

Alabama

Arkansas

California

Colorado

Connecticut

Delaware

DC

Florida

Georgia

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maryland

Massachusetts

Michigan

Minnesota

Missippi

Missouri

Nebraska

New Hampshire

New Jersey

New York

North Carolina

Pennsylvania

Rhode Island

South Carolina

South Dakota

Tennessee

Utah

Vermont

Virginia

West Virginia

Wisconsin

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Navigating the Coventry Medical

Provider Directory Website

Use this search tool to locate Medical Providers

ONLY If your claims are administered by

ProSight

• Go to http://coventrywcs.com/client-tools/index.htm

• Select the radial button for First Health Portal Login/Coventry login (GeoAcess Channeling Tools)

• In the client ID field , type in “SSols”

• A new page will appear, click on the link “Channeling Tools”

• The next page will give you four options to choose from:

• Address Search: This option is a radius search from a centralized address.

• Name Search: Allows the user to look up a certain provider in the database by name or phone.

• Region Search: This option allows the user to search in a specific region such as city, county, zip code, etc.

• Quick Search: A search using a limited number of specialties for providers who provide initial treatment to a maximum radius of 35 miles around an address. Creates output to a custom Worksite Poster or Directory.

• Worksite Posters: This option allows the user to make a Worksite Poster with the closest network providers while following all jurisdictional regulations and guidelines.

ADDRESS SEARCH

Begin by selecting the Network you wish to search. Enter your address. You must enter at least a valid ZIP Code or a City/State combination. At the bottom of the page you may choose: Provider Types, Specialties and/or distance. Once you click on “find providers” your results will be displayed.

NAME SEARCH

Use the Name Search tab if you already know a Provider’s name, group affiliation or phone REGION SEARCH

Use this feature if you are searching for a provider in a specific area. QUICK SEARCH

Use this tab if you are searching for ONLY one of the following: Family Practice, Internal Medicine,

Occupational Medicine, Emergency Medicine and Occupational Medical Clinics within 35 miles of a specific address.

WORKSITE POSTER (WSP)

This page is used to create Worksite Posters or batches of Posters. For your convenience, you can upload your Locations and create your posters!

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250 Progressive Way Westerville, OH 43082 800.777.3574 progressive@progressive-medical.com www.progressive-medical.com

888.908.MEDS

You may contact Progressive Medical for issues with your card, prior authorization or claim rejections, by calling 888.908.6337.

Pharmacist:If you experience any problems,

please call 888.908.6337.

Disclaimer: It is important to note the issue will be determined by the claims department and the confirmation of this treatment/ service request is in no way intended as an endorsement of the treatment/service request, nor is it intended to interfere with the provider from his or her duty to adhere to any applicable practice standards.

Progressive Medical, Inc. has been chosen to manage your workers' compensation prescription plan on behalf of your insurer or employer.

Below is your First Fill® card that allows you to fill your initial workers’ compensation prescriptions at your local pharmacy at no extra cost to you.

Instructions for the Company

x Fill in the ID/Auth# per the First Fill card below along with the name, date of birth and gender.

x Instruct the injured worker to take the First Fill card and their prescription to the pharmacy.

x Report the claim to the appropriate insurance company/TPA.

Note: If additional medications are required, the claims professional should contact Progressive Medical to use our Retail Drug Card program. If additional First Fill cards are needed or if you have any questions about the use of this program, please contact Progressive Medical at 888.908.MEDS and ask for the Pharmacy Services Coordinator.

Instructions for the Injured Worker

x Report your injury to the appropriate staff.

x Below is a First Fill card that will allow you to obtain the “initial” prescriptions needed upon injury with no out-of-pocket expense.

x A sample list of participating pharmacy chains that accept this First Fill card is on the back of this sheet.

x Present your First Fill card and your prescription to the pharmacist.

x This card is for a one time use to receive your medications per your company benefits. Use of this card is only for your workers’ compensation injury for which this claim was made.

x If you have any questions, call Progressive Medical toll-free at 888.908.MEDS. Our Client Services Specialists are available 24-hours a day to take care of your needs.

PLEASE NOTE: IF YOUR WORKERS’ COMPENSATION CLAIM IS ACCEPTED, YOU WILL RECEIVE

A RETAIL DRUG CARD IN THE MAIL. PRESENT THAT CARD WHEN FILLING OTHER INJURY-RELATED PRESCRIPTIONS.

Questions?

888.908.6337

Questions?

888.908.6337

FIRST FILL® CARD

BIN#: Restat 600471

PCN: 7777

Company Name: Prosight Specialty Insurance

Group/Plan#: J013

Person Code: 00 (zero, zero)

ID/Auth#:

SSN (9 digits, no dashes) Date (6 digits, no dashes) E.g. if the SSN is 000-00-0000and today’s date is May 21,

2007, the ID/Auth# is 000000000052107.

Injured Worker’s Name:

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250 Progressive Way Westerville, OH 43082 800.777.3574 progressive@progressive-medical.com www.progressive-medical.com

Cuando una persona lesionada necesita medicamentos de inmediato, la opción con la tarjeta First Fill (Surtir primero) le permite autorizar estas recetas y ayudarle a recuperarse.

Instrucciones para la compañía

x Anote el número de identificación/autorización en la tarjeta First Fill al verso junto con el nombre, la fecha de nacimiento y el sexo.

x Indique al trabajador lesionado que lleve la tarjeta First Fill y su receta a la farmacia.

x Reporte la reclamación a la aseguradora/TPA apropiada.

Nota: Si se requiere recibir medicamentos adicionales continuamente, el profesional de reclamaciones debe ponerse en contacto con Progressive Medical para utilizar nuestro programa de Tarjeta de Medicamentos al por Menor. Si se necesitan tarjetas First Fill adicionales, o si tiene alguna pregunta sobre cómo usar este programa, llame a Progressive Medical al 888.908.MEDS y pida hablar con el Coordinador de Farmaceuta.

Instrucciones para el trabajador lesionado:

x Reporte la lesión al personal apropiado.

x En la parte inferior de este formulario aparece una tarjeta First Fill que le permitirá obtener los medicamentos “iniciales” necesarios para la lesión sin costo de su propio bolsillo.

x A continuación se encuentra una lista de muestra de las cadenas de farmacias participantes que aceptan esta tarjeta First Fill.

x Presente su tarjeta First Fill y su receta al farmacéutico.

x Esta tarjeta sólo se puede usar una vez para recibir sus medicamentos de acuerdo con los beneficios de su compañía. Utilícela únicamente para la lesión que cubre el seguro de compensación a los trabajadores para la cual se presente el reclamo.

x Si tiene alguna pregunta, llame gratis a Progressive Medical al 888.908.MEDS. Nuestros Especialistas de Servicios al Cliente están disponibles las 24 horas del día.

NOTA: SI SE ACEPTA SU RECLAMO DE SEGURO DE COMPENSACIÓN A LOS TRABAJADORES, RECIBIRÁ POR CORREO UNA TARJETA DE FARMACIA AL POR MENOR. PRESENTE ESA TARJETA AL SURTIR RECETAS SUBSECUENTES RELACIONADAS CON EL TRABAJO.

Sample Listing of Participating Pharmacies

The below is a sampling of pharmacies that honor our program:

Albertsons Longs Drug Stores Costco

Safeway Giant Eagle Pharmacy Winn Dixie Pharmacy Meijer Pharmacy Publix Pharmacy CVS Pharmacy Walgreens Rite Aid Pharmacy Discount Drug Mart K-Mart Fred Meyer Target Pharmacy Tops Markets Medicine Shoppe Wal-Mart Pharmacy

For additional pharmacies within your area call Progressive Medical’s Client Services department at 888.908.6337 or visit our website at www.progressive-medical.com. Go to Workers’ Compensation, Tools and Resources, Pharmacy Look-Up and enter your city, state or zip code and click on “Submit”. You will see a listing of pharmacies in your area.

¿Preguntas?

888.908.6337

¿Preguntas?

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Dear Policyholder:

For your convenience, we have included the following website addresses to your state’s Workers’ Compensation web page. From the links below, you can access any forms that you might need when submitting a Workers’ Compensation claim.

Alabama http://dir.alabama.gov Alaska http://www.labor.alaska.gov/wc/ Arizona http://www.ica.state.az.us/ Arkansas http://www.awcc.state.ar.us/ California http://www.dir.ca.gov/dwc/ Colorado http://www.colorado.gov/ Connecticut http://wcc.state.ct.us/ Delaware http://www.delawareworks.com/ DC http://www.does.dc.gov/does/ Florida http://www.myfloridacfo.com/wc Georgia http://sbwc.georgia.gov/portal/ Hawaii http://hawaii.gov/labor/rs/ Idaho http://www.iic.idaho.gov/ Illinois http://www.iwcc.il.gov/ Indiana http://www.in.gov/wcb/ Iowa http://www.iowaworkforce.org Kansas http://www.dol.ks.gov/wc/about.html Kentucky http://www.labor.ky.gov/ Louisiana http://www.laworks.net/ Maine http://www.maine.gov/wcb/ Maryland http://www.wcc.state.md.us/ Massachusetts http://www.state.ma.us/wcac/ Michigan http://www.michigan.gov/wca Minnesota http://www.doli.state.mn.us/ Mississippi http://www.mwcc.state.ms.us/ Missouri http://labor.mo.gov/ Montana http://erd.dli.mt.gov/ Nebraska http://www.wcc.ne.gov Nevada http://dirweb.state.nv.us/WCS/wcs.htm New Hampshire http://www.labor.state.nh.us/ New Jersey http://lwd.state.nj.us/labor/wc/wc_index.html New Mexico http://www.workerscomp.state.nm.us/ New York www.wcb.state.ny.us North Carolina http://www.ic.nc.gov/forms.html North Dakota http://www.workforcesafety.com/ Ohio http://www.ohiobwc.com/ Oklahoma http://www.owcc.state.ok.us/ Oregon http://www.cbs.state.or.us/wcd/ Pennsylvania http://www.portal.state.pa.us Rhode Island http://www.dlt.ri.gov/wc/ South Carolina http://www.wcc.sc.gov/Pages/default.aspx South Dakota http://dlr.sd.gov/workerscomp/ Tennessee http://www.tn.gov/labor-wfd/ Texas http://www.tdi.state.tx.us/forms/ Utah http://www.laborcommission.utah.gov/ Vermont http://www.labor.vermont.gov/ Virginia http://www.vwc.state.va.us/portal/ Washington http://www.lni.wa.gov/ West Virginia http://www.wvinsurance.gov/ Wisconsin http://dwd.wisconsin.gov/wc/ Wyoming http://doe.wyo.gov/aboutus/

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