1

GSD/RMDWorkers’ Compensation

BureauWorkers’ Compensation

Insurance for all State Employees and State

Universities.Approximately 52,000

EmployeesApproximately 150 State

AgenciesEight Adjusters Santa Fe/LC

2

1991 WC Statutes (new Law)Posters with information have to be

posted at all employees work site to advise right to file an injury.

Future medical treatment for reasonable and necessary treatment to THAT injury stay open.

Medical impairments to the injured body parts are set by statute.

First choice of Health Care Provider, first 60 days.

3

4

Ins. PremiumsInsurance Premiums are based on 5 yr.

Experience/Exposure.

ERTW Modified duty saves money on premiums, since WC benefits are not being paid out, only medical coverage.

Process of filing a ClaimWhen an employee gets injured or thinks they

come in contact with an illness at work due to “COURSE & SCOPE OF THEIR EMPLOYMENT”, file a Notice Of Accident (NOA).

Employer should have on-going training for employees on this process.

Notice to Employer/Supervisor is sufficient. Once Employer has knowledge then it is Employers responsibility to file the paper work.

Not up to Employer or Supervisor to deny the claim.

5

6

7

Medical CareIn an Emergency an Injured worker should

be directed to Hospital ER nearest to the place of employment.

ER is no one’s first choice of Health Care.If not an Emergency an Employer can

direct injured worker to a Medical provider OR can Permit injured worker to choose a medical provider of their choice for the first 60 days. We do not have a Contract Medical Provider any where in the State.

8

ContinuedIf the doctor that the injured worker

chooses, does not accept workers comp insurance let them know they can find a doctor that does accept WC Insurance, direct them to the WCA for information as to what doctors accept workers compensation insurance.

WCA Offices 1 800 841-6000Albuquerque, Farmington, Las Cruces, Las Vegas, Lovington, Roswell and Santa Fe 9

EMPLOYERS’ REPORT NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION EMPLOYERS' FIRST REPORT OF INJURY OR ILLNESS

2410 CENTRE AVE. SE PO BOX 27198 ALBUQUERQUE, NM 87125-7198

OFFICIAL USE ONLY

PLEASE PRINT IN BLACK INK OR TYPE.

G E N E R A L

EMPLOYER ( NAME & ADDRESS INCL ZIP )

CARRIER / ADMINISTRATOR CLAIM #

OSHA LOG NUMBER

REPORT PURPOSE CODE

JURISDICTION

JURISDICTION CLAIM NUMBER

INSURED REPORT NUMBER EMPLOYER'S LOCATION ADDRESS ( IF DIFFERENT )

LOCATION #

PHONE NUMBER

EMPLOYER FEIN

INDUSTRY CODE

C A R R I E R

C L A I

M S

A D M I N

CARRIER ( NAME, ADDRESS & PHONE NO ) RISK MANAGEMENT DIVISION P.O. BOX 6850 SANTA FE, NEW MEXICO 87502

POLICY PERIOD TO

CLAIMS ADMINISTRATOR ( NAME, ADDRESS & PHONE NO )

CHECK IF APPROPRIATE

SELF INSURANCE

CARRIER FEIN 85-0000565

POLICY / SELF-INSURED NUMBER SELF INSURED

ADMINISTRATOR FEIN

AGENT NAME & CODE NUMBER

E

M P L O Y E E

NAME ( LAST, FIRST, MIDDLE )

DATE OF BIRTH

SOCIAL SECURITY NUMBER

DATE HIRED

STATE OF HIRE

ADDRESS ( INCL ZIP )

GENDER

MARITAL STATUS

OCCUPATION/JOB TITLE OR (SOC) CODE

MALE

UNMARRIED SINGLE/DIVORCED

FEMALE

MARRIED

EMPLOYMENT STATUS

UNKNOWN

SEPARATED

PHONE NUMBER

# OF DEPENDENTS

UNKNOWN

NCCI CLASS CODE

W A G E

RATE PER:

DAY

MONTH

# DAYS WORKED/WEEK

FULL PAY FOR DAY OF INJURY?

YES

NO

WEEK

OTHER:

DID SALARY CONTINUE?

YES

NO

O

C

C

U

R

R

E

N

C

E

TIME EMPLOYEE BEGAN WORK

AM

DATE OF INJURY/ILLNESS

TIME OF OCCURRENCE

AM

LAST WORK DATE

DATE EMPLOYER NOTIFIED

DATE DISABILITY BEGAN

PM

PM CONTACT NAME / PHONE NUMBER SUPERVISOR OR HR

TYPE OF INJURY/ILLNESS

PART OF BODY AFFECTED

DID INJURY/ILLNESS EXPOSURE OCCUR ON EMPLOYER'S PREMISES? TYPE OF INJURY / ILLNESS CODE

PART OF BODY AFFECTED CODE

YES

NO

DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED

ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED

SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED

WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED

HOW INJURY OR ILLNESS / ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL.

CAUSE OF INJURY CODE

DATE RETURNED TO WORK

IF FATAL, GIVE DATE OF DEATH

WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED?

YES

NO

WERE THEY USED?

YES

NO

T R E A T M E N T

PHYSICIAN / HEALTH CARE PROVIDER ( NAME & ADDRESS )

HOSPITAL ( NAME & ADDRESS )

INITIAL TREATMENT

NO MEDICAL TREATMENT

MINOR: BY EMPLOYER

MINOR CLINIC/HOSPITAL

EMERGENCY CARE

O

T

H

E

R

WITNESSES ( NAME & PHONE # )

HOSPITALIZED > 24 HRS

FUTURE MAJOR MEDICAL/ LOST TIME ANTICIPATED

DATE ADMINISTRATOR NOTIFIED

DATE PREPARED

PREPARER'S NAME & TITLE

NM WCA FORM E1.2 EQUIVALENT TO OSHA'S FORM 301 FORM IA-1 (7/02) IAIABC 2002 Completion of this form is not an admission that the claim is compensable under the Workers’ Compensation Act.

10

11

12

13

14

15

Doctor Query FormThis form should be sent with an injured

worker to Dr. every time they have an appt.Can they work?Can they work with restrictions?Can they work Part Time?Can employer accommodate restrictions?

16

17

18

Investigation of a Claim

19

Adjuster assigned the claim will determine if claim is compensable based on information given, medical evidence, WC Statutes, and Case Law

If Adjuster denies claim, injured worker has a right to file a complaint with WCA, goes to Mediation, if not agreed by both parties, goes into hearing with WCA Judge, and can go into Trial.

Benefit payment

If a doctor states NO Work, WC will start benefits on the 8th day of lost time. Temp. Total Disability (TTD) at 66 2/3 of injured workers Average weekly wage. This is calculated by the gross income for 26 weeks prior to the date of injury. There is a Max Comp Rate and that changes every January.

January 1, 2014 = $759.89 Max RateMinimum Rate = $ 36.00 a weekContinue payment until released back to

work or can come back to modified duty with medical restrictions. 20

If Claim Is AcceptedMedical get paid to that injury for

reasonable and necessary treatment till resolved or on-going treatment is needed.

All medical bills and referrals are paid for reasonable and necessary treatment (PT,OT, MRI, x-rays, second opinions, IME).

If doctor determines injured worker can not work, Temporary Total Disability (TTD) is calculated after the 7 day waiting period and paid as WC Benefit.

Temporary Partial Disability (TPD).21

22

Average Weekly Wage Form (AWW)We will ask to fill this form from HR , we need to get average weekly wage according to NMWC Statute 5.21.20.Includes Gross income, Overtime, Shift Differential to include other part time work also. Impairment are also calculated according to the COMP Rate (66 2/3 % of AWW, taken from the AWW.For instance if an IW is at MMI, suffered a 10% impairment, the AWW wage is 500 the Comp rate is 333.33 x 10 % = $33.33 per week for 300 weeks or 500 weeks whole person. Scheduled injury, (knee, arm, leg) is so many weeks according to the ACT.

23

ADJUSTERS• AKEMI ROBLES (575) 521-6257 LAS CRUCES• SILVA, RAY (575) 521-5919 LAS CRUCES• ANDREA ARMENTA (505) 476-3762• TODD WILSON (505) 827-0451CINDY CARRILLO (505) 476-3871CHARLENE URBAN (505) 827-0338RICKY KITCH (505) 827-0272MARCEA DARK (505) 827-0347ANDREA CHAVEZ (505) 476-2174 CLAIMS

INFORMATIONCARL SANDOVAL (505) 476-3874 SCANNERCHERYL HUTTO (505) 827-2711 CLAIMS

INFORMATIONPATRICIA ZENDEL (505) 827-0253 BILLINGMARTIN SANDOVAL (575) 476-3787

BILLING

Bureau Chief, IDA SPENCE (505) 827-029924