docClaims Kit - ProSight Specialty Insurance
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Claims Kit - ProSight Specialty Insurance
WORKERS’ COMPENSATION Claims Kit 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. ProSight has partnered with a leading Workers’ Compensation claims service provider, Gallagher Bassett Services, to assist us in the administration of claims. Gallagher Bassett will be your primary point of contact for claims. To determine which office will be handling your claims, please refer to the map included with this packet. 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 [email protected] Phone: 800-774-2755 Fax: 855-657-3534 Need to Report a Claim? By e-mail: [email protected] 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: t*GZPVBSFB8PSLFST$PNQFOTBUJPO1PMJDZIPMEFSZPVBSFFMJHJCMFUP QBSUJDJQBUFJOPOMJOFSFQPSUJOHPGZPVS8PSLFST$PNQFOTBUJPO$MBJNT 3FHJTUSBUJPOJTSFRVJSFEGPSPOMJOFSFQPSUJOHTFFJOTUSVDUJPOTCFMPX Online: XXXOFUDMBJNOFU t5PSFHJTUFSGPSPOMJOFSFQPSUJOHQMFBTFF-NBJMZPVSSFRVFTUUP OFUDMBJNUBTLT!UOXJODDPNXJUIZPVSGVMMOBNFDPNQBOZ OBNFQIPOF OVNCFSGBYOVNCFSQPMJDZOVNCFS BOECFTVSFUPNFOUJPOUIBUZPVBSFB 1SP4JHIUDVTUPNFS Ȉ*GZPVIBWF BOZTVQQPSUJOHEPDVNFOUTSFQPSUTCJMMTFUD BTTPDJBUFEXJUI BOFXMZSFQPSUFEDMBJNQMFBTFXBJUGPSUIFFYBNJOFSTDPOUBDUJOGPSNBUJPO %POPUTFOEUIFTFEPDVNFOUTUPUIFDBMMDFOUFS. EXPERIENCED PROFESSIONALS. INSIGHTFUL SOLUTIONS.SM Workers’ Compensation Claim Handling Washington Montana New Hampshire Vermont North Dakota Maine Minnesota Oregon South Dakota Idaho Nebraska Pennsylvania Iowa Illinois Utah Colorado California New York Kansas Indiana Ohio Oklahoma New Mexico New Jersey Delaware Maryland West VirginiaVirginia Missouri Kentucky Arizona Rhode Island Connecticut Michigan Wyoming Nevada Massachusetts Wisconsin North Carolina Tennessee South Carolina Arkansas Mississippi Alabama Georgia Texas Louisiana Alaska Hawaii ProSight Specialty Insurance Florida Gallagher Bassett Services LWP Claims Solutions Monopolistic Claims Handling Offices | ProSight Specialty Insurance Mailing Workers’ Compensation Claims Department ProSight Specialty Insurance 412 Mt. Kemble Avenue Morristown, NJ 07960 [email protected] Phone: 800-774-2755 Fax: 855-657-3534 Contacts WC Claims Manager: Melissa Kovacsy [email protected] Lost Time Adjuster: Patrick Gano [email protected] Medical Only Adjuster: Melinda Bullock [email protected] 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 Claims Handling Offices | Alaska Mailing Wilton Adjustment Service, Inc. – 425 625 E. 34th Avenue, Suite 400 Anchorage, AK 99503 Phone: 907-276-3311 Fax: 907-276-7877 Contacts Branch Manager: Joanne Pride, x 3412 [email protected] Adjuster: McKenna Wentworth, x 3452 [email protected] Medical Only: Shea Loescher, x 3317 [email protected] Alaska Claims Handling Offices | Arizona Mailing Gallagher Bassett Services- 007 (Phoenix) PO Box 10849 Scottsdale, Arizona 85271 Phone: 480-586-9500 Fax: 480-443-8416 Toll Free: 800-231-3759 Contacts Branch Manager: Bruce Martin [email protected] Arizona Claims Handling Offices | Hawaii Mailing Gallagher Bassett Services -162 900 Fort Street, Suite 420 Honolulu, HI 96813-4511 Phone: 808-532-7362 Fax: 808-545-5967 Toll Free: 877-492-9645 Contacts Nadine Kurihara-Nakasu, Branch Manager [email protected] Hawaii Claims Handling Offices | Idaho Mailing Gallagher Bassett Services – 193 720 East Park Blvd., Suite 125 Boise, ID 83712 Phone: 208/345-8090 Fax: 208/345-3996 Toll Free: 866/217-1192 Contacts Regina Pearson, Branch Manager [email protected] Idaho Claims Handling Offices | Montana Mailing Gallagher Bassett – 080 (Missoula) 2501 Catlin Street, Suite 200 Missoula, MT 59801 Phone: 855-335-7892 Fax: 406-721-2735 Contacts Regina Pearson 208-515-3835 [email protected] Montana Claims Handling Offices | Nevada Mailing Gallagher Bassett Services – 156 P.O. Box 70030 Las Vegas, NV 89170 Phone: 702-789-4500 Toll Free: 866-889-4755 Fax: 866-823-4130 Contacts Charles Rostad, Branch Manager [email protected] (UPS, Federal Express, etc) 2110 E. Flamingo Road, Suite 314 Las Vegas, NV 89119 Nevada Claims Handling Offices | New Mexico Mailing Gallagher Bassett Services - 046 2424 Louisiana NE, Suite 220 Albuquerque, NM 87110 Phone: 505-837-2180 Fax: 505-837-2187 Toll Free: 866-859-2180 Contacts Regina Pearson, Branch Manager [email protected] New Mexico Claims Handling Offices | Oklahoma Mailing Gallagher Bassett Services - 132 6303 Waterford Blvd., Suite 120 Oklahoma City, OK 73118 Phone: 405/843-7244 Fax: 405/843-8658 Toll Free: 800/943-7244 Contacts Stacy Goble, Branch Manager [email protected] Oklahoma Claims Handling Offices | Oregon Mailing Gallagher Bassett Services – 155 (Portland) 4550 Kruse Way, Suite 155 Lake Oswego, OR 97035 Phone: 503-675-6575 Fax: 503-675-6574 Toll Free: 877-800-3059 Contacts Eric Sorem, Branch Manager [email protected] Oregon Claims Handling Offices | Texas Mailing Gallagher Bassett Services - 025 (Dallas) 6404 International Parkway, Suite 2300 Plano, Texas 75093 Phone: 972-931-6277 Fax: 972-931-6256 Toll Free: 800-382-0166 Contacts Terry Tarter, Branch Manager [email protected] Texas Navigating the Coventry Medical Provider Directory Website Use this search tool to locate Medical Providers ONLY If your claims are administered by Gallagher Bassett • Go to www.firsthealth.com/welcome • Enter Login ID: GBMCS • 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! Temporary Prescription Services ID For Claims Administered by Gallagher Bassett Attached you will find a prescription form (also called a temporary pharmacy card) that must be given to each and every employee when there is an on the job injury. Employees simply call the First Script number to locate a local pharmacy where they can get their Workers Compensation prescription(s) filled. It is a good idea to distribute these forms to your Supervisors, Team Leaders, and your Human Resources department so they are familiar with the form. Chances are they will receive the notices of injury and will likely be responsible for handing the form to the injured employee. PRESCRIPTION PROGRAM FOR WORK-RELATED INJURIES :HOFRPHWR)LUVW6FULSWDSKDUPDF\EHQHILWSURJUDPGHVLJQHGH[FOXVLYHO\IRUProSight Specialty LQSDUWQHUVKLSZLWK*DOODJKHU%DVVHWW6HUYLFHV,QFIRU\RXUZRUNSODFHLQMXU\ Injured Worker No Cost STEP 1 &RPSOHWHWKHLQIRUPDWLRQUHTXHVWHGLQWKHERWWRPSRUWLRQEHORZ STEP 2 3UHVHQWWKLVIRUPWR\RXUSKDUPDFLVWDORQJZLWKWKHSUHVFULSWLRQVIRU\RXU ZRUNUHODWHGLQMXU\ No Delay )LUVW 6FULSW LV DYDLODEOH DW RYHU SKDUPDFLHV QDWLRQZLGH 7R ORFDWH D QHDUE\ SKDUPDF\SOHDVHFDOO)LUVW6FULSW&XVWRPHU6HUYLFHDW1-866-445-7344 Feel Better Faster 3OHDVH QRWH WKDW )LUVW 6FULSW LV YDOLG RQO\ IRU PHGLFDWLRQV SUHVFULEHG WR WUHDW \RXU FRPSHQVDEOH ZRUNUHODWHG LQMXU\ <RX RU \RXU JURXS KHDOWK LQVXUHU DUH ILQDQFLDOO\ UHVSRQVLEOH IRU DQ\ RWKHU SUHVFULSWLRQV 7KH ZRUNHUV¶ FRPSHQVDWLRQ FDUULHU ZLOO GHWHUPLQHWKHFRPSHQVDELOLW\RIWKHFODLP Pharmacy Instructions 7KHLQMXUHGZRUNHU¶VHPSOR\HUSDUWLFLSDWHVLQ)LUVW6FULSWDSKDUPDF\EHQHILWSURJUDPDGPLQLVWHUHGE\Medco&DOO WKH )LUVW 6FULSW +HOS 'HVN KRXUV D GD\ GD\V D ZHHN DW 1-866-445-7344 ,I WKH 0HPEHU ,' QXPEHU LV QRW OLVWHG RQ WKLV IRUP SOHDVH SURYLGH WKH FODLPDQW LQIRUPDWLRQ LQGLFDWHG EHORZ WR UHFHLYH WKH 0HPEHU ,' 3OHDVH QRWH WKH ,' QXPEHU RQ WKH IRUP DQG UHWXUQ WR LQMXUHG ZRUNHU )LUVW 6FULSW FODLPV DUH VXEPLWWHG HOHFWURQLFDOO\ DQG HOHFWURQLFDSSURYDORIWKHFODLPZLOOEHUHWXUQHG Pharmacy: You will not be required to submit any paperwork for this claim and payment is guaranteed for all electronically accepted claims. Pharmacy: $W WKH UHTXHVW RI WKH ZRUNHUV FRPSHQVDWLRQ FDUULHU IRU WKLV FXVWRPHU SOHDVH XVH WKH IROORZLQJLQIRUPDWLRQWRSURFHVVDOOZRUNHUV FRPSHQVDWLRQSUHVFULSWLRQVRQOLQH 1DPHBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 661BBBBBBBBBBBBBBBBBBBB 5;352*5$0$'0,1,67(5('%<MEDCO 'DWHRIELUWKBBBBBBBBBBBBBBB *5283180%(5FSNCVTY 6WDWHZKHUHLQMXU\RFFXUUHGBBBBBBBBBBBBBBBBBBB %,1180%(5610014 'DWHRILQMXU\BBBBBBBBBBBBBBB &OLHQW 005174 0HPEHU,'BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB (PSOR\HU1DPH3UR6LJKW6SHFLDOW\ 0HPEHU,'LVJHQHUDWHGDWWLPHRIHQUROOPHQW (Above information to be completed by injured worker or supervisor) Programa de Beneficio FarmacéuticoPara Accidentes Laborales %LHQYHQLGR D )LUVW 6FULSW XQ SURJUDPD GLVHxDGR H[FOXVLYDPHQWH SDUD ProSight Specialty HQ DVRFLDFLyQFRQ*DOODJKHU%DVVHWW6HUYLFHV,QFSDUDVXOHVLyQUHODFLRQDGDFRQVXWUDEDMR Empleado Lastimado Ningún Costo Paso #1 &RPSOHWHODLQIRUPDFLyQUHTXHULGDHQHOIRUPXODULRGHODSDUWHLQIHULRU Paso #2 3UHVHQWH HVWD IRUPD D VX IDUPDFpXWLFR FRQ VX UHFHWD UHODFLRQDGD D VX DFFLGHQWHROHVLyQ Sin Tardanza/ Sin Demora )LUVW6FULSWHVWDGLVSRQLEOHHQPiVGHIDUPDFLDVHQWRGRHOSDtV3DUDORFDOL]DU XQD IDUPDFLD FHUFD GH XVWHG IDYRU GH OODPDU DO GHSDUWDPHQWR GH VHUYLFLRV GH )LUVW 6FULSWDO1-866-445-7344 Siéntase Mejor Mas Rápido )LUVW6FULSWHVVRORYDOLGRSDUDPHGLFLQDVUHFHWDGDVHQHOWUDWDPLHQWRGHVXOHVLyQTXH VHD GLUHFWDPHQWH UHODFLRQDGD R SRU FDXVD GH VX WUDEDMR 8VWHG R VXJUXSR GH VHJXUR PHGLFRVRQUHVSRQVDEOHVSRUFXDOTXLHURWUDUHFHWD(OVHJXURGHFRPSHQVDFLyQGHVX WUDEDMRGHWHUPLQDUiODFRPSHQVDFLyQGHVXFDVR Pharmacy Instructions 7KHLQMXUHGZRUNHU¶VHPSOR\HUSDUWLFLSDWHVLQ)LUVW6FULSWDSKDUPDF\EHQHILWSURJUDPDGPLQLVWHUHGE\Medco&DOO WKH )LUVW 6FULSW +HOS 'HVN KRXUV D GD\ GD\V D ZHHN DW 1-866-445-7344 ,I WKH 0HPEHU ,' QXPEHU LV QRW OLVWHG RQ WKLV IRUP SOHDVH SURYLGH WKH FODLPDQW LQIRUPDWLRQ LQGLFDWHG EHORZ WR UHFHLYH WKH 0HPEHU ,' 3OHDVH QRWH WKH ,' QXPEHU RQ WKH IRUP DQG UHWXUQ WR LQMXUHG ZRUNHU )LUVW 6FULSW FODLPV DUH VXEPLWWHG HOHFWURQLFDOO\ DQG HOHFWURQLFDSSURYDORIWKHFODLPZLOOEHUHWXUQHG Pharmacy: You will not be required to submit any paperwork for this claim and payment is guaranteed for all electronically accepted claims. Pharmacy: $W WKH UHTXHVW RI WKH ZRUNHUV FRPSHQVDWLRQ FDUULHU IRU WKLV FXVWRPHU SOHDVH XVH WKH IROORZLQJLQIRUPDWLRQWRSURFHVVDOOZRUNHUV FRPSHQVDWLRQSUHVFULSWLRQVRQOLQH 1DPHBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 661BBBBBBBBBBBBBBBBBBBB 5;352*5$0$'0,1,67(5('%<MEDCO 'DWHRIELUWKBBBBBBBBBBBBBBB *5283180%(5FSNCVTY 6WDWHZKHUHLQMXU\RFFXUUHGBBBBBBBBBBBBBBBBBBB %,1180%(5610014 'DWHRILQMXU\BBBBBBBBBBBBBBB &OLHQW 005174 0HPEHU,'BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB (PSOR\HU1DPHProSight Specialty 0HPEHU,'LVJHQHUDWHGDWWLPHRIHQUROOPHQW (Above information to be completed by injured worker or supervisor) 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 Kentucky http://www.labor.ky.gov/ North Dakota http://www.workforcesafety.com/ Alaska http://www.labor.alaska.gov/wc/ Louisiana http://www.laworks.net/ Ohio http://www.ohiobwc.com/ Arizona http://www.ica.state.az.us/ Maine http://www.maine.gov/wcb/ Oklahoma http://www.owcc.state.ok.us/ Arkansas http://www.awcc.state.ar.us/ Maryland http://www.wcc.state.md.us/ Oregon http://www.cbs.state.or.us/wcd/ California http://www.dir.ca.gov/dwc/ Massachusetts http://www.state.ma.us/wcac/ Pennsylvania http://www.portal.state.pa.us Colorado http://www.colorado.gov/ Michigan http://www.michigan.gov/wca Rhode Island http://www.dlt.ri.gov/wc/ Connecticut http://wcc.state.ct.us/ Minnesota http://www.doli.state.mn.us/ South Carolina Delaware http://www.delawareworks.com/ Mississippi http://www.mwcc.state.ms.us/ South Dakota http://dlr.sd.gov/workerscomp/ DC http://www.does.dc.gov/does/ Missouri http://labor.mo.gov/ Tennessee http://www.tn.gov/labor-wfd/ Florida http://www.myfloridacfo.com/wc Montana http://erd.dli.mt.gov/ Texas http://www.tdi.state.tx.us/forms/ Georgia http://sbwc.georgia.gov/portal/ Nebraska http://www.wcc.ne.gov Utah http://www.laborcommission.utah.gov/ Hawaii http://hawaii.gov/labor/rs/ Nevada http://dirweb.state.nv.us/WCS/wcs.htm Vermont http://www.labor.vermont.gov/ Idaho http://www.iic.idaho.gov/ New Hampshire http://www.labor.state.nh.us/ Virginia http://www.vwc.state.va.us/portal/ Illinois http://www.iwcc.il.gov/ New Jersey http://lwd.state.nj.us/labor/wc/wc_index.html Washington http://www.lni.wa.gov/ Indiana http://www.in.gov/wcb/ New Mexico http://www.workerscomp.state.nm.us/ West Virginia http://www.wvinsurance.gov/ Iowa http://www.iowaworkforce.org New York www.wcb.state.ny.us Wisconsin http://dwd.wisconsin.gov/wc/ Kansas http://www.dol.ks.gov/wc/about.html North Carolina http://www.ic.nc.gov/forms.html Wyoming http://doe.wyo.gov/aboutus/ http://www.wcc.sc.gov/Pages/default.aspx
