Coventry Workers' Compensation Network: Employee Information and Rights, Lecture notes of Nursing

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Coventry Workers’ Compensation Network

Employee Information Materials

Coventry Workers’ Comp Network

To All Employees:

Your employer is committed to your health and safety at the workplace. Our first concern is to keep injuries from happening. If you are injured, we want to help you get better and return to work as soon as it is medically safe.

Your employer has chosen Coventry Workers’ Comp Network as its Workers’ Compensation healthcare network. It is a network built around occupational healthcare providers.

We will provide services through our network of medical providers and facilities. Coventry Workers’ Comp Network is a nationally recognized company that specializes in treating injured workers and helping them return to work.

The network includes occupational health clinics and doctors who will provide you with medical treatment. Your doctor will also manage your return to work with your employer.

Under the program, you will receive:

 A primary treating doctor  Other occupational health services and specialists  Emergency healthcare services  Medical care if you are working or traveling outside of the geographic services area

The Coventry network has been built to provide you with timely and quality medical care. It is easy to access, and is here to provide you with quality medical care and assist you in returning to health and a productive life.

The enclosed materials will give you information to help you through your work-related injury or illness.

Coventry Workers’ Comp Network

your request for review, the insurer will tell you its decision. If you do not agree with the final decision of the insurer, you have the right to file a complaint with the Texas Department of Insurance. Your complaint must include your name, address, telephone number, a copy of the insurer’s decision, and any proof you sent to the insurer for review. A complaint form is available on the department’s web site at www.tdi.state.tx.us. You may also ask for a form by writing to the HMO Division, Mail Code 103-6A, Texas Department of Insurance, P.O. Box 149104, Austin, Texas 78714-9104.

When waiting for the insurer to make a decision or the Texas Department of Insurance to review your complaint, you may choose to receive all healthcare from the network. You may be required to pay for healthcare services received out of the network if it is decided that you do live in the network’s service area.

A provider listing is available at your worksite and through the network website, http://www.geoaccess.com/cvty/default.asp?company=1&client_ID=TXHCN. It is updated every three months and identifies providers who are taking new patients.

Changing Doctors

It may happen that you become dissatisfied with your first choice of a treating doctor. You can select an alternate treating doctor from the list of network treating doctors in the service area where you live. We will not deny a choice of an alternate treating doctor, however, before you can change treating doctors a second time, you must get permission from us.

Referrals

You do not have to get a referral if you have an emergency health condition. All healthcare services that you request will be made available by the network on a timely basis, as required by your medical condition. This includes referrals. All healthcare services, including referrals, will be made available no more than 21 days after you make a request.

Payment for Healthcare

Network doctors have agreed to look to the insurer for payment for your healthcare. They will not look to you for payment. If you obtain healthcare from a doctor who is not in the network without prior approval from Coventry, you may have to pay for the cost of that care. You may only access non-network healthcare providers and still be eligible for coverage of your medical costs if one of the following situations occurs:

 Emergency care is needed. You should go to the nearest hospital or emergency care

facility.

 You do not live within the service area of the network.

 Your treating doctor refers you to an out-of-network provider or facility. This referral must

be approved by Coventry Workers’ Comp Network.

 You have chosen your HMO primary care doctor. Your doctor must agree to abide by

the network contract and applicable laws.

Coventry Workers’ Comp Network

Complaints

You have the right to file a complaint with Coventry Workers’ Comp Network. You may do this if you are dissatisfied with any aspect of network operations. This includes a complaint about your network doctor. It may also be a general complaint about the Coventry Workers’ Comp Network. Please read the enclosed Coventry Complaint Procedures or call the Coventry Workers’ Comp Network Complaint Line at (800) 262-6122, option 4 to have your questions answered.

Coventry Workers’ Comp Network 3200 Highland Avenue Downers Grove, IL 60515 800/262- Grievance Coordinator, Option 4 Grievance_Coordinator@cvty.com

Texas law does not permit Coventry to retaliate against you if you file a complaint against the network. We also can not retaliate if you appeal the decision of the network. The law also does not permit us to retaliate against your treating doctor if he or she files a complaint against the network or appeals the decision of the network on your behalf. You also have the right to file a complaint with the Texas Department of Insurance. The Texas Department of Insurance Complaint Form is available on the department’s web site at www.tdi.state.tx.us or you may request a form by writing to the HMO Division, Mail Code 103-6A, Texas Department of Insurance, P.O. Box 149104, Austin, Texas 78714-9104.

What to do if you are injured on the job

If you are injured while on the job, tell your employer as soon as possible. A list of network doctors in your service area is posted at your worksite. A complete list of doctors is also available. You will be given more instructions on how to get treatment through the Coventry Workers’ Comp Network. Or, you may contact us directly at the following address and/or toll- free telephone number:

Coventry Workers’ Comp Network 720 Cool Springs Boulevard Suite 300 Franklin, TN 37067 1-800-873-

We will help you get an appointment with a network doctor.

In case of an emergency

If you are injured and it is an emergency, you should seek treatment at the nearest emergency facility as soon as possible. This also applies if you are injured outside the service area. It also applies if you are injured after normal business hours.

Coventry Workers’ Comp Network

 Botox injections

 Joint steroid injection

 Durable Medical Equipment (DME) billed charges greater than $500 per item (either purchase or expected cumulative rental)

 TENS units

 External and implantable bone growth stimulators

 Spinal cord stimulators

 Psychological testing and psychotherapy, repeat interviews, and biofeedback unless the service is part of a pre auth or division exempted returned rehabilitation program

 Psychotherapy with social worker, psychologist, or psychiatrist

 Biofeedback

 Chronic pain management/interdisciplinary pain rehabilitation

 Skilled nursing visits

 Nursing home, skilled nursing facility, convalescent, or residential care admissions

 Investigational or experimental procedures service or device for which there is early developing scientific or clinical evidence demonstrating the potential efficacy of the treatment, service, or device but that is not yet broadly accepted as the prevailing standard of care

 Chemical dependency programs

 Discograms

 Power traction devices such as Vax-D

 Drugs not included in the division’s formulary

 Required treatment plans

 Treatment and services that exceed or are not addressed by the Commission adopted treatment guidelines protocols and are not in a treatment plan pre auth by the carrier

 Treatment of an injury or diagnosis that is not accepted by the carrier following the treating doctors examination to define the compensable injury

 Repeat individual diagnostic study, with a reimbursement established in the current Medical Fee Guideline of greater than $350 or without a reimbursement rate in Medical Fee Guidelines (unless otherwise specified)

The number to call to request one of these treatments is 1-866-931-5100.

If a treatment or service request is denied, we will tell you in writing. This written notice will have information about your right to request a reconsideration or appeal of the denied treatment. It will also tell you about your right to request review by an Independent Review Organization through the Texas Department of Insurance.

Coventry Workers’ Comp Network

Employee Acknowledgment of Workers’ Compensation Network

I have received information that tells me how to get healthcare under Workers’ Compensation insurance.

If I am hurt on the job and live in the service area described in this information, I understand that:

1. I must choose a treating doctor from the list of doctors in the network. Or, I may ask my HMO primary care physician to agree to serve as my treating doctor.
2. I must go to my treating doctor for all healthcare for my injury. If I need a specialist, my treating doctor will refer me. If I need emergency care, I may go anywhere.
3. The insurance carrier will pay the treating doctor and other network providers.
4. I might have to pay the bill if I get healthcare from someone other than a network doctor without network approval.

_____________________________________________________ _________________

Signature Date

_____________________________________________________

Printed Name

I live at: ____________________________________________________________ Street Address

---

____________________________________________________________

City State Zip Code

Name of Employer ________________________________________________________

Name of Network ________________________________________________________

Coventry Workers’ Comp Network

EMPLOYER INFORMATION FORM: Coventry Workers’ Compensation Network

Welcome to your Workers’ Compensation healthcare provider network program.

Your insurance carrier has chosen Coventry Workers’ Comp Network, a Workers’ Compensation healthcare network certified by the State of Texas, to offer a Workers’ Compensation healthcare provider network program. The necessary materials to implement the program are enclosed to help prepare you when an injury occurs.

Components of the program:

 Preferred provider network

 Employee educational materials

 Toll-free first report of injury

 Utilization management (Pre-authorization)

 Telephonic and on-site case management (may include vocational services)

 Complaint process

Employer instructions:

 Read the enclosed network educational materials and post the “Notice of Network ”.

 Distribute network educational materials when initiating the program within three (3) days of hiring an employee and at the time of injury.

 Document the method of delivery of educational materials, to whom the materials were delivered, the location of the delivery, and the date delivered.

 Be sure that all employees sign the Employee Acknowledgment letter and maintain it in the employee’s personnel file. An employee who refuses to sign remains subject to network requirements. Document a refusal to sign the acknowledgment in the employee’s personnel file.

 Review the provider panel postings to ensure that the suggested medical providers are within the geographical service area of the worksite. You may call Coventry at 1-800-243-2336 for additional doctors.

 When an injury occurs, report it immediately to your claims administrator. If necessary, provide or arrange transportation of the injured employee to the network provider, or if appropriate, to the nearest emergency facility.

Coventry Workers’ Comp Network

Coventry Workers’ Compensation Network

Certified in the following 231 Texas counties

Anderson

Andrews

Angelina

Aransas

Armstrong

Archer

Atascosa

Austin

Bailey

Bandera

Bastrop

Baylor

Bee

Bell

Bexar

Blanco

Borden

Bosque

Bowie

Brazoria

Brazos

Briscoe

Brooks

Brown

Burleson

Burnet

Caldwell

Callahan

Calhoun

Cameron

Camp

Carson

Cass

Castro

Chambers

Cherokee

Clay

Cochran

Collin

Coke

Coleman

Colorado

Comal

Comanche

Concho

Cooke

Coryell

Crane

Crosby

Dallas

Dallam

Dawson

Deaf Smith

Delta

Denton

Dewitt

Dickens

Donley

Duval

Eastland

Ector

Ellis

El Paso

Erath

Falls

Fannin

Fayette

Fisher

Floyd

Franklin

Fort Bend

Freestone

Frio

Gaines

Galveston

Garza

Gillespie

Glasscock

Goliad

Gonzales

Gray

Grayson

Grimes

Gregg

Guadalupe

Hale

Hall

Hamilton

Hansford

Hardin

Harris

Harrison

Hartley

Haskell

Hays

Hemphill

Henderson

Hidalgo

Hill

Hockley

Hood

Hopkins

Howard

Houston

Hudspeth

Hunt

Hutchinson

Jack

Jackson

Jasper

Jefferson

Jim Hogg

Jim Wells

Jones

Johnson

Irion

Karnes

Kaufman

Kendall

Kenedy

Kent

Kerr

Kleberg

Kimble

Lamb

Lamar

Lampasas

Lavaca

Lee

Leon

Liberty

Limestone

Lipscomb

Live Oak

Llano

Loving

Lubbock

Lynn

Madison

Marion

Martin

Mason

McCulloch

McLennan

McMullen

Medina

Menard

Midland

Milam

Mills

Mitchell

Motley

Montague

Montgomery

Moore

Morris

Nacogdoches

Navarro

Newton

Nolan

Nueces

Ochiltree

Oldham

Orange

Coventry Workers’ Comp Network

Approved Service Areas