TOM MONTGOMERY, NGU RISK MANAGEMENT & SAFETY ENGINEERING & CLAIMS MANAGEMENT
All of us at Tennessee Risk Management Trust and Safety Engineering Consultants value our continued relationship with you and are excited to work with you in the coming year.
As you are aware, the Tennessee’s Workers’ Compensation Statute has undergone some drastic changes, which applies to all injuries occurring on or after July 1, 2014. We hope you had an opportunity to attend the webinar we sponsored today or any other seminars that provided the important information of the updates and changes.
Attached is a claims packet to assist you in reporting your workers’ compensation claims. We have included necessary forms and a check list of items needed when processing a claim. This will help to ensure we are all in compliance with the requirements of the new workers’ compensation law and to avoid financial penalties.
Some of these forms will be new to you, while others you’ll be familiar with, but they now must be completed more thoroughly and in a timely manner, again, to avoid financial penalties.
First Report of Injury C-20. Within 24 hours, this form must be completed and sent to us when an employee has been injured in the course and scope of his or her employment.
*Verified Wage Statement. The new law requires a wage statement to be fully completed including “number of days”, “week ending”, and “gross wages”. This should be sent in with First Report of Injury. The wage statement will still be completed for the 52 weeks prior to the date of injury. (A salary sheet or printout is not acceptable)
**Panel of Physicians C-42G. This must be signed and dated by the employee and returned to the claims adjuster. This form is not new, however the new law does have guidelines that require it be a “valid panel”. For instance, if you have a doctor that has retired or no longer accepts workers’ compensation patients, you need to make updates to your panel immediately to avoid financial penalties.
HIPPA Release. Effective 7-1-2014, C-31 medical releases will no longer be used. Please have the injured employee sign, date and return a HIPAA release form to the claims adjuster.
Employee Accident Report. We now must require that the employee complete this and submit it with First Report of Injury to help with claims investigation and determination of appropriate medical treatment.
Supervisor’s Accident Investigation Report. The injured employee’s supervisor will need to complete this and submit it this with the First Report of Injury to assist with our claims investigation.
Accident Witness Report. You must have any witness complete this and return to the claim adjuster.
The following forms will not be necessary on the simplest medical only claims. They will be required on more involved claims such as more serious medical only claims, lost-time claims and all claims that involve impairment ratings. The adjuster may need this information on any claim to hasten RTW.
Written Job Description. Please provide a job description for each injured employee to accompany the First Report of Injury.
Employer’s Prior Employment History as contained within your personnel records. Please provide with the First Report of Injury form.
Employee’s Highest Level of Education. Please provide with the First Report of Injury form.
Employers and carriers are subject to fines and penalties as indicated above. These range from $50 to $10,000 per violation.
Please feel free to contact us with any questions you may have – we are here to help!
BOE Claims – Contact TNRMT
888.743.4336
615.953.6292 (fax)
Dawn Wiles, Supervisor, ext 396
Kay Hager, ext 331
Sandra Thompson, ext 240
Anne Bible, ext 270
Diane Gruenewald, ext 137
All Other Claims – Contact Safety Engineering & Claims Management
866.826.4274
615.826.6378 (fax)
Kathy Kinard
Jennifer Hall
* Verified Wage Statement: Penalties are possible for non-compliance.
** Panel of Physicians C-42G: Penalties are possible for non-compliance. Please submit and updated panel to us as soon as possible.