Provided 6-17-16 1516 RTKL 0181 PHILADELPHIA SCHOOL DISTRICT Office of School Safety Directive #17 SUBJECT: INJURY ON DUTY I. POLICY A. B. C. Personnel who incur an injury as a direct result of their job performance, shall notify their immediate supervisor, and then call the School District of Philadelphia’s Workers’ Compensation third party administrator, PMA at 1-888476-2669 OR www.PMAMC.com If you have any problems contact your case agent. You must comply with all the requirements of this directive or it may result in the denial of benefits. All employees who incur injuries shall be treated at an approved clinic. Personnel who elect to receive treatment from a private physician or hospital will not be reimbursed for such treatment. The only exception to this provision is in cases of serious emergencies when personnel are taken to the nearest medical facility. A supervisor or an administrator will notify the Police Radio Dispatcher (Between 6P.M. and 8:30A.M. at 215-400-6000) or the Incident Control Room (During normal business hours at to alert them of the severity of the injury and details involved. II. TREATMENT A. School police personnel injured on duty shall be sent or taken immediately to one of the following clinics, EXCEPT IN SERIOUS EMERGENCIES. III. PROCEDURE A. HANDLING EMERGENCIES 1. In emergencies, the injured employee shall be taken to the nearest hospital for first aid treatment. 2. A supervisor, an administrator, or if not available, a School Police Officer will notify the Police Radio Dispatcher (215-400-6000) (Between 6P.M. and 8:30A.M.) or the Incident Control Room (During normal business hours at ) to alert them of the severity of the injury and details involved. 3. A supervisor will immediately be dispatched to the hospital and another supervisor will be sent to the scene of the injury to gather more information. 4. The pertinent Commander shall be made aware of the emergency. 5. After the emergency situation is under control, the injury is to be officially reported. 1 - 17 B. REPORTING INJURY 1. When a work-related injury is claimed, the injury must be reported within 24 hours to the supervisor. a. Officers must acknowledge the receipt of the “Employer’s/Employee’s Rights/Obligations” letter which is available at SPO’s work location. This form must be completed, signed and returned to the Workers’ Compensation Office and a copy must be sent to the Administrative Lieutenant of School Safety at 215-400-4711. b. On every visit to the Compensation Clinic, your paperwork must be faxed to the Administrative Lieutenant of School Safety at 215-400-4711. 2. The supervisor must contact the Incident Report Desk, complete an incident report, and call PMA at 1-888-476-2669 to report the injury. 3. Officers must select from one of the designated health care providers from the closest region’s panel listing. a. The Health Care Providers List shown in the “Notice to Employees” is available at your work location and should be posted in administrative offices, faculty lounges, employee bulletin boards, and first aid stations. b. If continued treatment is required, for the first 90 days, SPO must use one of the School District’s designated Health Care Providers. After 90 days, if treatment is needed, a private doctor may be seen. 7-12-04 Revised 06-10-11 JUNE 2015 BY ORDER OF THE CHIEF SAFETY EXECUTIVE OFFICE of SCHOOL SAFETY 2 - 17 PROCEDURES FOR HANDLING A WORKERS COMPENSATION CLAIM Emergences Treatment 911 For chest pains, unconscious, severe bleeding, poisoning or other scenario where time is a critical element. Employee Requirements Report to principal or principal’s designee Sign Rights & Obligations (DO NOT SEND HOME) Fax a copy of your Workman’s Compensation paperwork to the Administrative Lieutenant of School safety at Complete EH-31 Http://philasd.org go to sitemap, than forms and insert EH-31 Principal Reporting Incident Desk PMA (Pennsylvania Manufactures Association) 1-888-476-2669. Medical Treatment PPO First Fill Report Pay Codes 78 Worker’s compensation (including TAP if less than full pay) 04 If claim is denied by PMA or if employee does not come back to work after released (even if released with restrictions). Return to work Return with restrictions Temporary Alternate Work Program Supplemental Agreement for Compensation Change pay codes. Litigation Plan on appearing for a trial BY ORDER OF THE CHIEF SAFETY EXECUTIVE OFFICE of SCHOOL SAFETY 3 - 17 Office of Risk Management 440 North Broad Street, Suite 325 Philadelphia, Pa. 19130 Workers’ Compensation Staff Miriam Ortolaza Specialist @philasd.org 215-400- Return to Work Carol Ann Kenney @philasd.org 215-400 Payroll Carol Ann Kenney @philasd.org 215-400- PLEASE NOTE THAT FRAUD CLAIMSARE COMMUNICATED IN CONFIDENCE AND WILL KEPT CONIDENTAIL. PMA 1-888-476-2669 INCIDENT DESK 215-400STATE INSURANCE FRAUD REPORTING NUMBER: 1-888-565-4372 BY ORDER OF THE CHIEF SAFETY EXECUTIVE OFFICE of SCHOOL SAFETY 4 - 17 WORKERS’ COMPENSATION PROCEDURE MANUAL (Effective August 1,2009) School District of Philadelphia BY ORDER OF THE CHIEF SAFETY EXECUTIVE OFFICE of SCHOOL SAFETY New Procedure For Filing a Workers’ Compensation Claim 5 - 17 (effective August 1, 2009) 1. Immediately notify your Climate and Safety officer on any claim that appears to need emergent care. (e.g., problems breathing, chest pains, severe headaches, disoriented affect, severe bleeding, poisoning, sexual assault). 2. Call the School District Serious Incident Desk at 215-400- . (They will give you an incident report number.) 3. The injured employee must sign the Workers’ Compensation Employee Notification (“Employee Notification” form, also called the Rights and Obligations form) and give a copy of the form to the injured employee. a) Unless it is a true emergency where the injured employee is unable to sign, the injured employee must sign the form before they leave the building. i) If they are unable to sign the Employee Notification, send them the notice by certified mail / Return Receipt Requested. ii) If they refuse to sign the Employee Notification, call in a secretary or other administrator to witness the refusal to sign. Give the injured employee another chance to sign. If he / she refuses, write, “Mr. _________ refused to sign this notice.” You sign and date the notation and have the witness sign the notation. If either witness’s signature is illegible, print the name as well. iii) You keep the original in the employee’s file and fax the side with the signature to the Office of Risk Management 215-400 4. File the claim with PMA by going online www.PMAMC.com . are no longer the Districts TPA). USER NAME: (Do not call Sedgwick as they PASSWORD: If you cannot get access to the PMA claim site call PMA at 1-888-476-2669. You will get a claim number on the spot. You will put this onto the pharmacy card (Step 6) 5. Give the injured employee the Medical Provider List and explain that they must obtain their treatment through one of these doctors or the District will not be responsible for the bills. 6. Give the injured employee the pharmacy card (the “tmesys” card) and explain to the injured employee that they should give this to the pharmacist, that it will act like a prescription card so that they do not need to pay anything out of pocket. Fill in the injured employees name for him / her and put the claim number in the sect5ion asking for the Social Security Number. If you have any questions, concerns or problems, please contact, Workers’ Compensation Section at 215 BY ORDER OF THE CHIEF SAFETY EXECUTIVE OFFICE of SCHOOL SAFETY 6 - 17 WORKER’S COMPENSATION EMPLOYEE NOTIFICATION Workers’ Compensation Information (1) The workers' compensation law provides wage loss and medical benefits to employees who cannot work, or who need medical care, because of a work-related injury. (2) Benefits are required to be paid by your employer when self-insured, or through insurance provided by your employer. Your employer is required to post the name of the company responsible for paying workers' compensation benefits at its primary place of business and at its sites of employment in a prominent and easily accessible place, including, without limitation, areas used for the treatment of injured employees or for the administration of first aid. (3) You should report immediately any injury or work-related illness to your employer. (4) Your benefits could be delayed or denied if you do not notify your employer immediately. (5) If your claim is denied by your employer, you have the right to request a hearing before a workers' compensation judge. (6) The Bureau of Workers' Compensation cannot provide legal advice. However, you may contact the Bureau of Workers' Compensation for additional general information at: Bureau of Workers' Compensation, 1171 South Cameron Street, Room 103, Harrisburg, Pennsylvania 17104-2501; telephone number within Pennsylvania (800) 482-2383; telephone number outside of this Commonwealth (717) 772-4447; TTY (800) 362-4228 (for hearing and speech impaired only); www.state.pa.us, PA Keyword: workers comp. BY ORDER OF THE CHIEF SAFETY EXECUTIVE OFFICE of SCHOOL SAFETY 7 - 17 Management Tmesys First Fill Program Corp. PMA. f) INJURED PRESCRIPTION CARD GARRJER EMPLOYER PMA Management Corp DiStriCt Of Philade'Phi? Noticelo Pharmacists:Calthe Tmesys Pharmacy Heb Deskat INJURED WORKER NAME 300.964.2531toesiahlish benefit eligtriity and C?tah the med . 1d he at. Pam Single SourceSolution esignae ?SOCIAL SECURITY NUMBER DATE OF INJURY r0" W?Hk?lh Tmesys? Pharmacy Help Desk 600.964.2531 Mall? locardhuldar: Th's prescription card be [reamed medicated 1dr 'niury. Forinwmaim regth pharmacies in yourarea ooan he Tmesys Injumdwarkcr Intonation Group 311188.5915426. NDC (04261: Code 2 CAL Envoy Elin 002538: Processing Code Enmy?ccr. :5 FT: 3e 551-1; .In r:i Frames-5r :t'l bark for online adjudication of approved bene?ts fer the injured waiter. (Ctrtalong outer dotted line and told it center] Your employer, School District of Philadelphia and your workers? compensation claims administrator, PMA Management Corp. are providing prescription benefits through Tmesys. an online Pharmacy Bene?ts Manager. The attached cut?outTmesys First Fill Prescription card will make the process of obtaining medications for your injury easier and more convenient. Simply presentthis card to any of our more than 55.000 participating pharmacies nationwide? including Hawaii and Puerto Rico. and your prescription will be filled at no out?of?pocket expense to you. Your use of this card is limited to those prescriptions medically related to an injury that is considered to be covered under the applicable state workers' compensation law. Should you have any questions regarding our program or for the locations of a participating network pharmacy near you. please contact Tmesys at 866.599.5426. Sincerely. Tmesys HOW TO LOCATE A TMESYS PHARMACY: 1. Call Tmesys at 366.599.5426. A Tmesys representative will be more than happy to assist you with the location of a participating pharmacy in your area. 2. Visit our pharmacy locator on the web at Underthe ?Quick Link" section to the left of your screen. you'll find the Pharmacy Locator. PD. Box 152539 Ta mp a. FL 33584-523 9 9 Help Desk: 866 599.5426 BY ORDER OF THE CHIEF SAFETY EXECUTIVE OFFICE of SCHOOL SAFETY 8?17 in You must continue to visit one of these persons listed above: if you need treatment, for ninety {90) day from the date of your first visit. If you do not, your employer may not he required to pay these services. i After this ninety (90) day period, if you still need treatment and your employer had provided a list as set forth above, you may choose to go to another licensed physician or practitioner of the healing arts for treatment. You must notify your employer of this action within five (5) days of your visit to the person of your choice, or your employer may not be required to pay for these services. it Your bills will he paid for IF: your licensed physician or practitioner of the healing arts ?les reports as required. [These reports must be ?led within ten tilt) days after your first visit and at least once a month for as long as treatment continues.) In the event a posted panel physician recommends invasive surgery, you may seek a second opinion with a physician of your choice. If you choose to undergo the invasive surgery, you must use a posted physician for the treatment. in If no list is provided as above: you may go to a licensed physician of practitioner of the healing arts of your choice. i If one of the persons listed above refers you to another licensed specialist, the panel physician will recommend an approved provider. 0 If you are faced with a medical emergency, you may secure assistance from a hospital or physician or practitioner of the healing arts of your choice. i In the event another provider is needed, contact Plvla lvlanagement Corp. at {888) Name: Philadelphia School District Address: 440 North Broad Street, 3rd Floor Philadelphia. PA 19130 Generated: Radius: 2D milels} REMEMBER, IT IS IMPORTANT TO TELL YOUR EMPLOYER ABOUT YOUR INJURY This mater a is provided for nlom'ationa purposes only and is not meant to be legal advise. any person reading or otherwise using the information contained here acknow edges that the information is provided as a service and is not authon'z ng any soecif treatment or course of treatment. Furlher. use of any provider listed do es not verify or con?rm coverage under the Werlrers' Compensation Act and PM is not responsible for any losses incurred as a resu of any person re ying on this information. BY ORDER OF THE CHIEF SAFETY EXECUTIVE OFFICE 0f SCHOOL SAFETY