Claims Tips

Here's some useful information pertaining to claims.

Senate Bill 189
You’ve probably heard about Senate Bill 189, signed by Governor Jerry Brown on October 13, 2017 changing  Cal. Lab. Code §§ 3351 & 3352 regarding workers' compensation exclusions. You can read the entire text of the new law here.
 
Under prior law (established by AB 2883) qualified individuals could waive workers' compensation coverage for themselves, but the waivers were only effective when accepted by insurers and could not be backdated if submitted and accepted after December 31, 2016. Click here to learn more and to obtain the Waiver and Waiver instructions.

Expanded Language Offerings for Claims Materials
The California Division of Workers’ Compensation provides employee claims forms and workers’ compensation factsheets in Chinese, Korean, Tagalog, Vietnamese, English, and Spanish. We provide English and Spanish language forms in the Claims Kits we mail to you. However, if you want the forms and factsheets in any of the above-mentioned languages, you can access the Claims Resources list to download the materials.

Medical Access Assistants
In accordance with California Labor Code Section 4616(a)(5), effective January 1, 2014, Republic Indemnity will be using ACTEC as Medical Access Assistants for our Medical Provider Network. They will be available at 888-545-3795, from 7:00 a.m. until 8:00 p.m. Monday through Saturday, to respond to injured workers, provide network physician referrals, and coordinate the scheduling of appointments with claims adjusters.

Medical Provider Network (MPN)
What is a Medical Provider Network and what is the advantage of using Republic Indemnity's MPN? Access our Medical Provider Network FAQs and learn everything you need to know about California MPNs.

5-Ways to Report a New California Claim
It’s our goal that your employees receive quality medical treatment and return to work in the shortest possible time. To achieve this goal, it’s imperative that any injury be reported immediately. When reporting new claims, choose the method that works best for you. For our California policyholders, our Reporting a Claim 5-Ways 5-Days pamphlet outlines the five methods for reporting new California workers’ compensation claims within five days of every industrial injury or occupational illness for which medical treatment costs are incurred.

California Drug Formulary AB 1124 and Utilization Review SB 1160
The California Division of Workers’ Compensation (DWC) under the authority of Assembly Bill 1124, requires the adoption of an evidence-based workers’ compensation Drug Formulary on January 1, 2018. The goal is to improve the quality of care for injured workers by establishing a list of preferred cost-effective and readily available medications, while encouraging the use of the most appropriate drug to treat the injury or illness.

In the new Formulary, drugs are classified as either Exempt or Non-Exempt. Exempt drugs may be dispensed without pre-approval from the insurance carrier, but Non-Exempt drugs will have to be pre-approved before dispensing. Exempt drugs include many antibiotics and common medications such as Tylenol, Diclofenac, Ibuprofen, among others. Non-Exempt medications include but are not limited to Opioids, Lyrica, Flexeril, and “compounded medications.”

Other Formulary categories include the following: Not Listed, which will require prior authorization; and
Perioperative and Special Fill, which may be dispensed without prior authorization under certain conditions.

For more information about the Drug Formulary, visit the Division of California Workers’ Compensation website.

Utilization Review
Senate Bill 1160, which is effective January 1, 2018, will allow medical treatment for an accepted body part or condition without  prospective utilization review if that treatment is provided within 30 days of the date of injury (with certain exceptions). Therefore, it is critical to report claims promptly and refer injured workers to physicians within the Medical Provider Network to ensure they will receive prompt and appropriate medical treatment. For more information about Senate Bill 1160 click here.