GO 300-05 Workman's Compensation Flashcards
Adjuster.
An employee of the Third Party Administrator who investigates and adjudicates
insurance claims.
Third Party Administrator (TPA).
Independent administrator contracted by the City of
Houston to be responsible for the adjudication of workers’ compensation claims including
payments to recovering employees and health care providers in compliance with the law.
City of Houston Supervisor’s Incident Report.
Form used to document an employee’s injury. This report provides a description of how the injury occurred, location of the injury, and the employee’s personal information.
Employees who are injured or potentially exposed to a communicable disease while in the course and scope of employment with the City of Houston (COH) shall:
a. Immediately notify or arrange for the notification of a supervisor. This shall be done, if physically possible, no later than 24 hours following the time of the injury or exposure.
b. Seek immediate medical attention if necessary and avoid any activity that may aggravate the injury. Employees shall seek medical attention from a treating physician who accepts workers’ compensation patients. Failure to treat with an approved treating physician may make the employee ineligible for benefits under the Texas Workers’ Compensation Act.
c. Review, initial, and sign the GOH On the Job Injury Reference Sheet with a supervisor, if physically possible. Employees shall follow the rules and procedures listed on this form.
d. Employees who have potentially been exposed to a communicable disease shall also submit to baseline blood tests within ten calendar days following the exposure to a communicable disease. Employees shall complete the required injured on duty (IOD) forms including the Affidavit of Exposure to a Communicable Disease. Additionally, employees shall review and adhere to procedures outlined in General Order 300-21, Communicable Disease Policy.
It is the supervisor’s responsibility to ensure all of the initial IOD forms and required workers’
compensation forms and documents are completed and forwarded to the Health and Safety
Unit (HSU) within 24 hours after being made aware of the injury or event, or as soon as
practicable. Upon being notified of an occupational injury or potential exposure to a
communicable disease, a supervisor shall:
a. Arrange for prompt medical treatment of the employee, if necessary.
b. Advise the employee to seek medical attention from a treating physician that accepts workers’ compensation patients. Failure to treat with an approved treating physician may make the employee ineligible for benefits under the Texas Workers’ Compensation Act.
c. Initiate the process of filing the workers’ compensation claim by completing the required IOD paperwork. Completely fill out the City of Houston Supervisor’s Incident Report form with the injured employee as soon as possible, but no later than 24 hours after being made aware of the injury or event. The City of Houston Supervisor’s Incident Report form shall be
completed even if the employee does not seek medical attention. The HPD incident number (if applicable) shall be documented in the comments section of the form.
d. Review with the employee, the GOH On the Job Injury Reference Sheet and have the employee initial, sign, and date this form. Additionally, supervisors shall request for the employee to complete, sign, and date the Authorization for Disclosure of Protected Health Information form. If the employee refuses to initial, sign, or date any of the IOD forms, the supervisor shall document the refusal on each form that the employee refused to acknowledge. The supervisor shall also have a witness sign and date the form noting the refusal.
e. Report the claim via telephone to the Third Party Administrator’s Claim Reporting Service (CRS) as soon as possible, or within 24 hours after being made aware of the injury or event. Obtain a reference number from the CRS and document the number on the City of Houston Supervisor’s Incident Report form. If the supervisor is unable to contact the administrator within 24 hours following the report of injury, the supervisor shall contact HSU for further instructions.
f. Forward a copy of the completed IOD forms via fax or email to HSU within 24 hours following the report of injury or exposure. The originals should then be forwarded directly to HSU via interoffice mail.
g. Provide the injured employee with a copy of all completed IOD forms and workers’ compensation information documents including:
1. City of Houston Supervisor’s Incident Report
2. GOH On the Job Injury Reference Sheet
3. Rx Card/Rx Pharmacy Network Information Sheet
4. City of Houston Summary Workability Guidelines E. 0. 1-33 booklet
h. Provide the employee information on the Family and Medical Leave Act (FMLA), if applicable. FMLA notice is required whenever an employee reports a condition covered under FMLA guidelines (see General Orders 300-09, Absence from Duty - Classified and
900-01, Absence from Duty- Civilian).
________ do not have the authority to authorize medical treatment or benefits. However, _______may inform a treating physician that a claim of occupational injury shall be or has been reported to the COH’s Third Party Administrator (TPA) and direct the treating physician to the TPA for authorization for treatment.
Supervisors
Supervisors shall forward all owe __________ after they are received from an injured employee. When a supervisor is made aware that the owe Form-73 reflects that the employee may return to work with restrictions, the supervisor shall take the steps required under General Order 300-10, Transitional Duty Assignment.
Form-73 forms and treating physician’s statements to HSU
Supervisors shall immediately notify _________ when becoming aware of an injured employee using scheduled or unscheduled leave for vacation.
HSU
Supervisors shall maintain contact with ______________ while they are on injury leave either by telephone or personal visits.
Injured Employees
Supervisors shall document the ____, ____, and ____of any contacts. The purpose of maintaining contact with the injured employee is to determine the employee’s status and to assist in any manner to facilitate recovery and expedite the return to
duty.
date, time, and results
Unless otherwise directed by the employee’s _____________, supervisors shall contact an employee on injury leave at a minimum of once a week.
division commander
Supervisors shall conduct a scheduled or unscheduled personal visit with any employee who has been on injury leave for ___consecutive calendar days.
30
Supervisors shall continue to conduct personal visits with the injured employee at a minimum of once every ____ consecutive
calendar days until the employee returns to duty
30
When an employee is absent for over ____ consecutive calendar days for any reason, the employee’s supervisor shall instruct the employee to submit to a drug test immediately upon returning to work
30
