SCHOOL POOL FOR EXCESS LIABILITY LIMITS
JOINT INSURANCE FUND
ACCASBOJIF, BCIPJIF, & GCSSDJIF
PACCASBO BCIP GCSSD SEJIF
REVISED OCTOBER 2013
SPELLJIF Claim Coordinator’s Handbook Revised 10/13
Workers’ Compensation Claims
(Employee injuries sustained on the job)
Types of Claims/Objectives/Reporting Instructions
I. Types of Losses to be Reported:
• Any injury sustained by an employee of a member district during the course of his/her employment regardless of whether medical treatment is required (traumatic injuries). • Any injury allegedly sustained by an employee of a member district arising from an
exposure suffered during the course of his/her employment over a period of time (occupational disease injuries).
1) To record all incidents even if they are not claims. A claim is when an injured employee wants to see a doctor.
2) To promptly refer an injured employee for medical attention.
3) To quickly report the claim to QualCare to ascertain compensability.
WHAT TO DO WHEN AN EMPLOYEE GETS HURT ON THE JOB
1. Show genuine concern for the injured employee's welfare. 2. Direct injured employee to the School Nurse for triage.
3. Claim Coordinator to work with injured employee in completing theEmployee Report.
4. If needed, direct injured employee to your authorized District physician. You can use the "Employee Authorization for Medical Attention Form" (sample attached), at your district’s option.
Do not use the emergency room unless emergency treatment is required.
Emergency Room vs. Urgent Care Centers – See page 17
5. Call QualCare using the toll free telephone number and report the claim immediately.
A. Take all of the information necessary to complete the First Accident Report
SPELLJIF Claim Coordinator’s Handbook Revised 10/13 B. Immediately assign a Medical Care Coordinator or a Nurse Case Manager to follow up with the employee and physician to manage medical treatment and return to work status.
C. QualCare will immediately notify Qual-Lynx of the claim.
D. QualCare will fax a copy of the First Accident Report Confirmation (FARC) and a First Report of Injury or “F.R.O.I.” (samples attached), to the District Claim Coordinator (DCC). The DCC needs to verify all information on both reports and provide all corrections to QualCare. QualCare will transmit this information to Qual-Lynx and Qual-Lynx will first review the information for completeness and once satisfied will electronically file the “F.R.O.I.” with the State of New Jersey.
6. Once Qual-Lynx is notified about your claim by QualCare, an adjuster will be assigned within 48 hours of the receipt of the notification. Once assigned, the adjuster will assign a claim number then call the DCC to gather additional information and discuss the claim. Once a claim number has been assigned the Qual-Lynx system will generate an Acknowledgment Letter that will be mailed to the DCC. The Acknowledgment will contain the name of the adjuster assigned and the claim number which you will use when following up or when transmitting additional documents to Qual-Lynx.
7. The District Claim Coordinator will receive a Duty Determination Instructions (DDI) form (copy attached) after every doctor’s office visit.
8. The District Claim Coordinator will keep in contact with the injured employee, the employee's supervisor, the managed care service and the claims adjuster.
9. The District Claim Coordinator will work with the injured employee’s direct supervisor in completing the Supervisor Report (copy attached).
Do not delay the reporting of Workers’ Compensation Claims! Claims should be reported within 24 hours of accident.
Do not hold up the claim simply because all of the information is not available. Provide as much information as you have at the time and indicate that
additional information will be sent later
MEDICAL TREATMENT BY A BOARD OF EDUCATION APPROVED PANEL PHYSICIAN WAS OFFERED AND DECLINED BY THE EMPLOYEE, AT THIS TIME. (Check If Appropriate)
PLEASE SIGN THE ABOVE AND FORWARD PROMPTLY. USE OTHER SIDE OF THE FORM TO PROVIDE ADDITIONAL INFORMATION.
PLEASE FILL OUT THIS FORM IN DETAIL. ANSWERING ALL QUESTIONS ASSURES PROMPT HANDLING OF YOUR CLAIM.
Name ___________________________________ Age ______ Phone No. _______________________________ Address _____________________________________________ Social Security No. ________________________ List all dependents (Full names, ages, relationship and birth dates) ______________________________________ __________________________________________ ________________________________________________ __________________________________________ ________________________________________________ Name of Employer ___________________________ Name of Supervisor ________________________________ How many hours a day do you work? ____________ How many days a week? ____________________________ What are your wages per hour? ___________ Per day? ________ Per week? _____________________________ Describe fully your physical trouble or disability ____________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Date and hour trouble first started ______________________ 19 _____ __________________ a.m./p.m.
Explain fully and exactly what happened to you, or how your physical trouble or disability first started. (You can help us give your case prompt and proper attention if you will answer this question completely. The following is an illustration of the way to answer this question: A piece of wood about two inches square was thrown a distance of six feet by a power saw, striking the outer surface of my right leg about five inches above the knee.”)
________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________
(IF YOU NEED MORE SPACE, PLEASE USE REVERSE SIDE OF THIS FORM.) Who witnessed the start of your trouble? Give names, addresses and phone numbers.
____________________________________________________________________________________________ If your disability was caused by another person, please give his name and address __________________________ ___________________________________________________________________________________________ Give date and hour on which you first started to lose time from work __________ _____________ a.m./p.m. When were you able to return to work? ______________ Are you fully recovered now? ______________________ If you are still having trouble, explain fully your present condition and what parts of your body are affected:
____________________________________________________________________________________________ ____________________________________________________________________________________________ Date on which you first saw doctor ________________________________________________________________ Give names and addresses of all doctors you have seen ________________________________________________ ______________________________________ Are you still receiving treatment? __________________________ Have you had this or any other injuries at any time in the past? __________________________________________ If so, explain the nature of that trouble and approximate date it happened __________________________________ ____________________________________________________________________________________________ Give name and address of employer for whom you were working at time of your previous trouble ______________ ____________________________________________________________________________________________ Give name and address of doctor who saw you for previous trouble _______________________________________ ____________________________________________________________________________________________ Dated ________________________ Signed ________________________________________________________
Where do I go? The Emergency Room? Or an Urgent Care Center?
When you have a life-threatening situation, such as chest pain, or a sudden and severe pain, the emergency department of the nearest hospital is the only option. If you went to an urgent care clinic they would just send you on to the ER in an ambulance. But, if your condition is less serious but still requires immediate attention choosing an urgent care facility can save time and money.
If you have a sprained ankle or an ear infection, you may end up waiting for many hours in the emergency room and paying hundreds of dollars. Most urgent care centers are open for extended hours and will be able to accommodate you more quickly.
When you need to go to the Emergency Room:
If you have a serious condition – stroke, heart attack, severe bleeding, head injury or other major trauma – go straight to the nearest ER. Don’t take a chance with anything life-threatening. The ER is the best place for these and other conditions including:
Severe Bleeding or Head Trauma Loss of Consciousness
Sudden loss of Vision or Blurred Vision
When an Urgent Care Center can better meet your needs.
After Occupational Medicine/Primary Care Provider’s business hours for treatment of:
Minor burns or injuries Sprains and strains
Allergic Reactions (non life-threatening) Rash or other skin irritations
Animal Bites Broken Bones
When In doubt, call ahead. If the urgent care clinic can’t accommodate your condition they will advise you to go to the nearest emergency facility.
TO: QualCare, Inc. 100 Decadon Drive
Egg Harbor Township, NJ 08234
FAX NUMBER: 609-927-0991
(Only for Workers' Compensation )
NUMBER OF PAGES SENT (#)
FROM: (Name of Claim Coordinator) (Name of District)
This is a: ____ New Claim
____ Additional Information on Existing Claim
(Claim Number, if known)
Date of Loss: ______________________________
Claimant Name: ____________________________
Always complete this form whenever transmitting Workers' Compensation Claims to QualCare
FIRST ACCIDENT REPORT CONFIRMATION
QUALCARE NOTIFIED ON CASE MANAGER Qual-Lynx QUALCARE 00106696 INJURY DATE
TIME 12:00:00AM CLAIM NUMBER
000000000 DATE OF BIRTH 12/10/1985 AGE 27
NAME TEST SAMPLE MARITAL STATUS GENDER M ADDRESS
123 NO NAME ST
EGG HARBOR TOWNSHIP, NJ 08234
DAYS WORKED SALARY JOB TITLE EMPLOYMENT STATUS SHIFT FT
HOME PHONE PAYMENT
CELL PHONE FREQUENCY
EMPLOYER ACCAS EGG HARBOR TWP BOE PHONE 609-653-0100
LOCATION ADDRESS 13 SWIFT DRIVE CONTACT SUSAN DIEFENBECK CITY, STATE, ZIP EGG HARBOR TOWNSHIP, NJ 08234
DATE EMPLOYER NOTIFIED
REPORTED BY X RECEIVED VIA PHONE WITNESS
NATURE OF INJURY PART OF BODY AFFECTED LOCATION OF ACCIDENT AGENT
HOW INJURY OCCURRED
DOMINANT HAND UNKNOWN PREVIOUS MEDICAL
PREVIOUS WORKERS' NOT REPORTED COMP INJURY
PRIMARY CARE NOT REPORTED
TREATMENT DIRECTED TO NA TREATMENT DIRECTED BY NA COMMENTS
TEACHER SALARY TYPE 12 MONTH CHILD INVOLVED NO
AGE OF CHILD
SPECIAL NEEDS CHILD
PREPARED BY AnnaMarie Finnegan DATE PREPARED DATE PRINTED 07/13/2012 2:08:36PM
ACCAS EGG HARBOR TWP BOE 13 SWIFT DRIVE
EGG HARBOR TOWNSHIP, NJ 08234 NJ
123 NO NAME ST
EGG HARBOR TOWNSHIP, NJ 08234
X X , , X X X X SAMPLE, TEST X X X 233429930 30 Knightsbridge Road QualCare, Inc. Piscataway, NJ 08854 30 6096530100 223614476 12/10/1985 000000000 M Full-Time 02/08/2011 AnnaMarie Finnegan NJ 223614476 12/31/9999 02/08/2011 SUSAN DIEFENBECK 6096530100 7ACCAS031
EMPLOYEE: QC CLAIM #:
DATE OF INJURY: EMPLOYER:
JOB TITLE: GROUP:
CONTACT: [Case Manager]
DATE OF VISIT: PHONE: (609) 653-8400
LEVEL OF FUNCTION: INDICATE RESTRICTIONS BELOW IF THEY APPLY TO INJURY:
May return to work. No restrictions of job activities required. In an 8 hour day, employee may:
Concurrent therapy may be required, but all essential job STAND / WALK SIT
functions may be performed safely and without harm to employee. 1-4 hours 1-3 hours 4-6 hours 3-5 hours May return to work with restrictions. 6-8 hours 5-8 hours May not return to work. Requires severe restrictions of physical DRIVE (if driving is part of job): HAND LIMITATIONS:
activities that include bed rest and restrictions to home only. Cannot drive Single grasping Employee is allowed to go to doctor's office and therapy only. < an hour Pushing / pulling
1-3 hours Fine manipulation 3-5 hours
INITIAL COMPLAINT: 5-8 hours
DX / ICD9: CAN EMPLOYEE DRIVE TO WORK IF YES NO
ALTERNATE DUTY IS PROVIDED? CAUSALLY RELATED TO INJURY: YES NO
VEHICLE TYPE EMPLOYEE MAY OPERATE PLEASE DESCRIBE ANY OTHER RESTRICTIONS THAT APPLY:
LIFTING AND OTHER PHYSICAL RESTRICTIONS
Foot pedals / repetitive use Reaching overhead Lifting or carrying Climbing more than less than __________ lbs. one flight of stairs
RESTRICTIONS ARE IN EFFECT UNTIL:
HAS EMPLOYEE ACHIEVED YES NO
MAXIMUM MEDICAL IMPROVEMENT? ANTICIPATED MAXIMUM MEDICAL IMPROVEMENT DATE:
EMPLOYEE WAS A NO SHOW FOR THIS APPOINTMENT PHYSICIAN:
ADDRESS: NEXT APPOINTMENT DATE: PHYSICIAN'S SIGNATURE: Phone:
FAX: CLAIMANT'S SIGNATURE:
SUBMIT ALL Qual-Lynx
MEDICAL BILLS TO: 100 Decadon Dr.
Egg Harbor Township, NJ 08234
BODY PART(S) INJURED:
All medical bills related to this case will be paid according to QualCare's negotiated terms.
INDICATE LEVEL OF PHYSICAL ACTIVITY
Additional treatment and referrals require prior authorization. Prescription(s) must be faxed with this form.
PT / OT: DIAGNOSTICS: SURGERY:
Fax: (609) 927-0991
URGENT: PLEASE FAX COMPLETED FORM WITHIN 24 HOURS AFTER EACH VISIT.
C:\Documents and Settings\mollendike\Desktop\School Forms\Supervisor Report.doc f:d\r\w\gcssdjif\forming\98-99\clmcoord\suprvisr.doc
___________________Board of Education
Please Circle: Vehicular Accident Non-Vehicular Accident Police Report Attached
Name of Injured ________________________________ Date/Time of Injury ___________________ Occupation __________________ Dept. _________________ Date of Hire ________________________ Nature of Injury ______________________________________________________________________ Entity Vehicle _________________________ Description of Damage ___________________________ Location of Accident ____________________________________________________________________
1. What job was employee doing including tools, machine, materials or vehicle used?
_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 2. How was employee injured?
_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 3. What improvements should be made with method, procedure or injured’s performance?
_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 4. What was defective or in an unsafe condition?
_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 5. If equipment, etc., was involved, where is equipment now? Please store any involved equipment for inspection purposes.
_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 6. What equipment should be used?
_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 7. What steps were taken to prevent similar injuries?
_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Supervisor’s Name _____________________________________________________________________ Title: ________________________________________________________________________________ Date of Report: ________________________________________________________________________
The Communication Process
Managed Care Nurse
What Are Their Responsibilities?
promptly report injury
provide a complete description
create internal reporting policy and procedure
ensure its enforcement and communication
monitor incident and claim activity
communicate with all players
NJ is one of only 12 states which allow
employer-directed medical care!
set up claim file
determine compensability within the statute
monitor activity for breaches of the statute
pay claims as appropriate
manage file through litigation
communicate with all players
Managed Care Nurse
- manage medical progress
speed up medical processes
work to get injured employee back to
full health as soon as possible
communicate with all players
see injured employees promptly
determine if injury is work related
monitor patient progress
communicate with all players
make return to work decisions!
Injured Employee Follows local proce-dures to report claim
Supervisor Completes Accident Investigation Report
Claims Coordinator Calls QualCare using FAR as a guide
overnight transmission of claim
QualCare takes claim
and enters it into Qual-Care system
*QualCare assigns claim
to Medical Case Coordinator
QualCare issues FARC
and FROI to Claims Coordinator with QC Claims Number Qual-Lynx contacts Employee, MD, and Employer to gather claim info Accident Investigation Report is sent to Safety
Director and Qual-Lynx
Employee, MD, and Employer to gather
Claims Coordinator Directs injured employee
to primary care MD
MD issues DDI to QualCare and Claims Coordinator
after every visit
Qual-Lynx issues FROI
to municipality and to State
claims acknowledge-ment to municipality
*QualCare assigns Nurse
Case Manager where re-quired
* Medical Case Coordinator is
as-signed to every case.
* Nurse Case Manager is assigned to