$mbjnt,ju /psui$bspmjob - falls lake ins claims kit.pdf · raleigh, nc 27624 - 7308 ... less likely...
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North CarolinaClaims Kit
By Mail: PO BOX 97308 Raleigh, NC 27624 - 7308
Email: [email protected] Call: TF (866) 459- 1349 Fax: TF (888) 629- 5821
Attention: CLAIMS DEPARTMENT
Falls Lake Fire & Casualty | Stonewood Insurance | Falls Lake National
Thank you for choosing Falls Lake Insurance Companies for your Workers’ Compensation needs.
We are pleased to provide support regarding the filing of claims and other state specific
information to assist in claims reporting. All information will be included in the enclosed Claims
Kit. Please review your policy when completing any information on the state-mandated posting
notices, specifically policy numbers and effective dates.
One of the most essential parts of a Workers’ Compensation claim is early reporting. This
facilitates timely investigation, payment of benefits and appropriate care for your injured worker.
Falls Lake National Insurance Company & Stonewood Insurance Company
To Contact Us:
Mail: PO BOX 97308
Raleigh, NC 27624 – 7308
Email: [email protected]
Call: TF (866) 459- 1349
Fax: TF (888) 629- 5821
Attention: CLAIMS DEPARTMENT
Welcome to Falls Lake Insurance Companies.
We look forward to working with you.
www.Fallslakeins.com
Falls Lake Fire & Casualty | Stonewood Insurance | Falls Lake National
North Carolina Claims Kit
In the state of North Carolina, Employers are required to comply with state law regarding
mandatory posting notices to be displayed in a conspicuous area of the workplace.
Required Posting (Form 17) – English
Required Posting (Forma 17) – Spanish
Below you will find the necessary forms to assist in filing a Workers’ Compensation claim with
Stonewood Insurance Company.
Forms
First Report of Injury (Form 19)
Use Stonewood’s approved managed care medical provider network for in-network Physicians.
Visit www.coventrywcs.com, Stonewood’s approved cost-containment vendor.
Click the “Locate a Provider” tab to begin.
A First Report of Injury (FROI) should be filed immediately after the employee is injured and/or
when the Supervisor is notified. To file the FROI, Employers may use the following methods:
Stonewood Insurance Company
Call: TF (866) 459- 1349
Fax: TF (888) 629- 5821
Attention: CLAIMS DEPARTMENT
Email: [email protected]
By Mail: PO BOX 97308
Raleigh, NC 27624 – 7308
HELPFUL LINKS
North Carolina Industrial Commission
Frequently Asked Questions
Falls Lake Fire & Casualty | Stonewood Insurance | Falls Lake National
Claims Guidelines:
1) Send your injured employee for medical treatment at a nearby urgent care or emergencyroom and request a post-accident urine drug screen. A post-accident screening isMANDATORY and must be performed on the date of the accident and/or date of notice.
2) Immediately notify and report any injury to Falls Lake Insurance Companies.
Report a New Claim:
Email: [email protected]
Call: TF (866) 459- 1349
Fax: TF (888) 629- 5821
Attention: CLAIMS DEPARTMENT
3) Please be prepared to provide the Claims Department with the following information:a) Your information
Policy number Telephone number Company contact
b) Injured employee information Name Social Security number and date of birth Address and telephone number Date of hire and occupation at time of injury
c) Incident information Date and time of the incident Location of the incident (on or off your premises) Supervisor of the injured employee Witnesses names and person to whom incident was reported Description of incident Injured body part (fatality) Name of treatment facility Results from the MANDATORY post-accident screening
d) Work status Was the injured employee paid in full for the date of incident Last day worked Has the claimant returned to work (exact date of return, light/full duty)
4) Stay in contact with your injured employee throughout their recovery. Continue to lethim/her know that they are a valued employee and that you are eager for them to return towork.
5) Refer to state-specific posting requirements contained in Claims Kit.
www.Fallslakeins.com
Falls Lake Fire & Casualty | Stonewood Insurance | Falls Lake National
Report workplace injuries within 24 hours
Late reporting drives medical costs higher andreduces workplace productivity.
Encourage employees to report any workplace injury toyour company's injury coordinator immediately. Call our toll-free number (866) 459-1349File your First Report of Injury within 24 hours. When in doubt, call the Stonewood Claims department.
Use Stonewood's approved managed caremedical provider network
Encourage early return to work for injured employees
Providing return-to-work options within the firstmonth after an injury leads to successful outcomes in95% of all cases.
Work with your Stonewood nurse and/or claims specialist to plan your employee's return to work. Communicate regularly with the employee to showconcern and encouragement, and to help monitorrecovery and rehabilitation. Provide light-duty work as a bridge to resuming full responsibilities.
Visit www.coventrywcs.com, Stonewood's approved cost-containment vendor.Click the "Locate a Provider" tab to begin.
As the graph below shows,Workers' Comp claims reported>7 days after an injury typicallyaverage over $5,400 more thanthose reported within 1-5 days.
Minimize fraud casesFaster return to work and employeehealing Expedited claims handling Reduced cost of claimsLess likely to involve an attorney
Early reporting results
in lower claims cost.
For in-network Physicians.
$0
$6,375
$12,750
$19,125
$25,500
1-5 D
ays
6-7 D
ays
7+ Day
s
How claims cost increasewhen injuries are not
reported promptly
HOURS
Benefits of early reporting...
Falls Lake Fire & Casualty | Stonewood Insurance | Falls Lake National
Keys to Managing Your Workers' Compensation Claims
Medical Cost Containment Program
Program DesignPharmacy Benefit Program Design
When a workplace accident or occupational injury occurs, Falls Lake Insurance Companies are ready to respond with our custom designed medical management and cost-containment program to address our customers' needs.
National Medical Bill Review
24/7 Nurse Triage Programs
Telephonic Case Management
Onsite Case Management
Durable Medical Equipment
Utilization Review
Pharmacy Benefit Management
National PPO Network
F a l l s L a k e F i r e & C a s u a l t y | S t o n e w o o d I n s u r a n c e | F a l l s L a k e N a t i o n a l
www.FallsLakeIns.com | MORE. BETTER.
Customized Formularies
Web-Based Claims Portal
Mail-Order Benefits
Pharmacy Drug Card
Proactive Narcotic Monitoring
First-Fill Benefits
24/7 Customer Care
Falls Lake Insurance Companies partners with Coventry and other national vendors to provide medical cost containment that includes cost-efficient medical intervention throughout the life of the claim.
Prescription Program For Work-Related Injuries
Injured Worker
No Cost
STEP 1 Complete the information requested in the bottom portion below.
STEP 2 Present this form to your pharmacist along with the prescriptions for your work-related injury.
No Delay First Script is available at over 70,000 pharmacies nationwide. To locate a nearby pharmacy, please call First Script Customer Service at 1-800-791-2080.
Feel Better
Faster
Please note that First Script is valid only for medications prescribed to treat your compensable work-related injury. You or your group health insurer, are financially responsible for any other prescriptions. The workers’ compensation carrier will determine the compensability of the claim.
Pharmacy Instructions
The injured worker’s employer participates in First Script, a pharmacy benefit program administered by Express Scripts (ESI). Call the First Script Help Desk, 24 hours a day, 7 days a week, at 1-800-791-2080. If the Member ID number is not listed on this form, please provide the claimant information indicated below to receive the Member ID #. Please note the ID number on the form and return to injured worker. First Script claims are submitted electronically and electronic approval of the claim will be returned.
Pharmacy: You will not be required to submit any paperwork for this claim and payment is guaranteed for all electronically accepted claims.
Pharmacy: Please use the following information to process all work-related injury prescriptions online.
Name: ________________________________________
Date of injury: _____/_____/_____
Member ID: ____________________________________
(Member ID # is generated at time of enrollment)
Employer Name:
Location Code: CC 997662620
RX PROGRAM ADMINISTERED BY: Express Scripts (ESI)
GROUP NUMBER: FSNCVTY
BIN NUMBER: 610014
(Above information to be completed by injured worker or supervisor)
Here's How NT24 Works...
We would like to introduce you to NT24, a nurse triage program for injured workers. The program is administered by Stonewood Insurance, a Falls Lake Company, and Coventry.
NT24 connects the injured employee with one of the NT24 highly trained RNs who perform triage
of the medical symptoms according to established guidelines, including proprietary workers
compensation medical triage guidelines. This process will help determine the level of care required,
i.e. self-care, referral to an urgent care facility or occupational medical clinic.
Non-english speaking callers can access bi-lingual (Spanish and English speaking) RNs and
interpreters to assist with the call.
If self-care is recommended, the NT24 RN will attempt to check back with the injured employee to
be sure he/she understands and follows the recommendations. In addition, injured employees are
provided instructions on how to call back at any time to discuss their injury and the self-treatment
plan.
NT24 is linked into the First Report of Injury (FROI) intake service. If an employee requires more
than self-care, the FROI is directly transmitted for claims management.
If an injured employee requires medical treatment, the NT24 channels him/her to a preferred or
panel provider.
The Benefits Are Clear...
Fewer emergency room visits
Immediate and appropriate direction of care for injured employees
Reduced lag time, reporting in hours due to around the clock
availability and immediate direction of care
Faster recoveries and early returns to work
Reduction in claim costs
Through NT24, your injured employees have access to registered nurses (RNs) 24 hours a day, seven days a week. A single call starts the notice of injury and triage process – a first step that ensures your injured employees receive prompt and appropriate care.
Falls Lake Fire & Casualty | Stonewood Insurance | Falls Lake National
To Speak with a
Registered Nurse
Regarding a Work
Related Injury Call:
1-855-474-0122 Service Available 24/7/365
Nurse Triage 24
Coventry NT24 Reference Guide
Information Instructions
TO SPEAK WITH A REGISTERED NURSE REGARDING A WORK RELATED INJURY CALL:
1-855-474-0122
24 HOURS PER DAY/365 DAYS PER YEAR
If an employee has sustained a work related injury that is not life, limb or eyesight threatening call the Coventry NT24 service and speak with a nurse at:
1-855-474-0122
INSTRUCTIONS FOR MANAGER REGARDING PROCESS WITH THE NURSE:
Provide a secure area for the employee to speak with the nurse.
Please inform the nurse of any language needs; bilingual nurses areavailable; Spanish and English. Other languages; the nurse will bring in aninterpreter prior to speaking with the employee
The nurse will ask questions to rule out an emergent situation. If thenurse does assess a life, limb or eyesight threatening situation, they mayrequest assistance in getting Emergency Medical Services.
The nurse will complete an assessment and derive at a medical care orself-care disposition.
The nurse will ask the employee to place the manager back on the phone.The nurse will communicate the instructions that were given to theemployee.
AFTER THE EMPLOYEE SPEAKS WITH THE NURSE:
Once the employee has completed their call:
The manager will assist per company policy to ensure that the employeeis able to follow the nurse’s recommendation
The manager will complete any internal reporting required per companypolicy
TO GET A PRESCRIPTION FILLED:
If an employee needs to go for medical care, the nurse can offer to provide the phone number to the employee.
POST ACCIDENT DRUG TESTING IS
REQUIRED
A post-accident drug and alcohol test is required of all reported workers’ compensation injuries within 24 hours of the employer’s knowledge of the injury.
THIS PROCEDURE IS NOT OPTIONAL.
NON-COMPLIANCE MAY RESULT IN CANCELLATION OF YOUR POLICY.
Refer to your policy.
WWW.FALLSLAKEINS.COM
Falls Lake Fire & Casualty | Stonewood Insurance | Falls Lake National