Medical care includes:
- Medically necessary drugs
- Assistive devices
Except for emergency cases, the health care provider who treats you must be authorized by the Workers' Compensation Board to treat injured workers.
Find a Board Authorized Provider
- You may search for a health care provider using the Board's Health Care Provider and IME Search; OR
- by phone: (800) 781-2362
With some exceptions (see below), you may receive care from any of the providers found through the link above, or from your own health care provider if your provider is Board-authorized. Your health care provider's office should be able to tell you whether or not they are is allowed to treat you for a work-related injury and should only treat you for medical conditions that are within their area of specialty.
If your employer participates in a Preferred Provider Organization (PPO) program, you will need to seek treatment from a participating health care provider who is part of that program.
The Workers' Compensation Law allows by negotiated labor agreement, a non-Workers' Compensation Board adjudication claim process called the Alternate Dispute Resolution (ADR) system, for employers and employees in the unionized construction industry. Injured workers covered by that system are required to obtain medical treatment from health care providers who participate in the ADR program.
Your health care provider is required to write reports about your treatment and send those reports to the Board and to the workers' compensation insurer if:
- you are unable to work because of your injuries or illness. A medical report is required as proof in order to be eligible for lost wage benefits.
- you are unable to work for an extended period of time. Medical reports are required at least every 90 days in order to remain eligible for lost wage benefits.
- your claim is disputed. The Board needs a medical report for your injury or illness to begin resolving your claim.
Health Care Expenses
Know your rights and responsibilities regarding health care expenses.
- Do not pay your health care provider or hospital for treatment you receive for your injury/illness. Your employer's workers' compensation insurer pays those bills unless the Board issues a decision that finds your claim to be invalid.
- Your health care provider may ask you to sign a Notice that You May Be Responsible for Medical Costs in the Event of Failure to Prosecute, or if Compensation Claim is Disallowed, or if Agreement Pursuant to WCL §32 is Approved (Form A-9). This form states that you will pay the bills if the Board disallows the claim, or if you drop the claim before it is accepted.
- If specific medical services are disputed, the workers' compensation insurer must pay any undisputed portion. The insurer must explain in writing why the services were not paid, and request any information needed to pay them.
- Keep receipts for travel expenses related to your injury. You may be reimbursed for mileage, public transportation or expenses incurred for treatment. Submit receipts to the workers’ compensation insurer with a Claimant’s Record of Medical and Travel Expenses and Request for Reimbursement (Form C-257).
Preferred Provider Organizations
The workers' compensation insurer or self-insured employer may use a network of providers, known as a Preferred Provider Organization (PPO), to care for its members. If your employer has elected to use this PPO, you must be notified in writing about the PPO, and you are required to seek initial treatment with a provider affiliated with the PPO.
However, after 30 days from the initial treatment date, you may select any authorized provider outside the PPO. If you decide to seek a provider outside the PPO, notify your insurer/self-insured employer in writing. This notification may be a simple letter specifying your intent to opt-out of the PPO network.
The insurer/self-insured employer has the right to require that you seek a second opinion from another PPO provider.
You can use any pharmacy, unless the workers' compensation insurance carrier or self-insured employer uses an independent pharmacy, pharmacy network, or pharmacy benefit manager (PBM).
Let the pharmacist know that you have a workers' compensation case. Many pharmacists will bill the insurer directly; however, the pharmacy can ask for payment of the prescription up front. If you pay for the prescription, the pharmacy can only charge the amount specified by law. You are not responsible for a co-payment (co-pay).
The insurer must pay any claim (either to the pharmacy or reimbursement to you) within 45 days of receiving the claim. If the insurer disputes that the claim or the prescribed medicine is for the work-related injury or illness, the insurer must pay any undisputed portion within 45 days, and either notify you that the claim is not being paid (and the reason) or request reasonable additional information.
Independent Pharmacy, Pharmacy Network or PBM
- If an insurer or self-insured employer uses an independent pharmacy, pharmacy network or PBM, the pharmacy/pharmacies should be within a reasonable distance from your home or employment, or offer mail order service. The insurer or self-insured employer must tell you, in writing, which local pharmacies you can use, and provide their locations and addresses. It must also tell you how to fill and refill prescriptions through the mail, internet, telephone or other means.
- You can purchase the drugs elsewhere if there is a medical emergency and it is not reasonably possible to immediately obtain the medicine you need from the pharmacies in the chosen network.
- Network pharmacies are paid directly. You are not responsible for any charges.
Opioid Pain Medications
If you are prescribed opioid pain medications such as OxyContin, Percocet and Vicodin, among others, you should know that these medications have serious side effects, can reduce your ability to function and are highly addictive.
Continued use of opioid pain medication causes changes in the brain and results in the need for higher dosages to obtain the same level of pain relief (called tolerance). Continued use of opioids can cause increased sensitivity to pain, and may even make the pain worse.
Some common side effects of opioid use include: drowsiness, severe sedation, dizziness, nausea, vomiting, constipation, confusion and memory loss. Severe side effects can include difficulty breathing, overdose and death. Uncomfortable withdrawal symptoms (a result of developing a dependence) may occur when opioids are reduced or stopped suddenly. Normal, day-to-day functioning may become difficult. Cravings for opioids may be uncontrollable, which can lead to use of other drugs and behaviors harmful to oneself or others (called addiction). If there are concerns that opioids are harming you or your loved one, don't hesitate to get help.
Substance Abuse Support Services
If you think you may need help, you (and/or your family members) should first discuss any opioid pain medication any concerns with your physician. Your physician can recommend the right specialist. Workers' compensation insurance will pay for treatment if it is recommended by a judge or approved by your workers' compensation insurance carrier.
The workers' compensation insurance carrier or self-insured employer will send you a Notice That Claimant Must Arrange for Diagnostic Tests & Examinations through a Network Provider (Form DT-1) if you are required to use a specific network provider for diagnostic tests. You should inform your health care provider(s) that the insurer has this requirement. You can also view a list of insurers/self-insured employers/claim administrators who have contracted with a Diagnostic Testing Network (DTN).
The insurer or self-insured employer cannot demand that you use a network provider for a diagnostic test in a medical emergency. It cannot demand that you use a network that does not have a provider or facility within a reasonable distance from your home or employment.
Medical Treatment Guidelines
The Workers' Compensation Board has Medical Treatment Guidelines that health care providers are required to use when treating certain injuries.
These guidelines allow the health care provider to perform much of your treatment without needing to ask the insurer for authorization. However, your health care provider may still need to ask for authorization before performing certain tests or procedures.
If you or your health care provider receives a notice that a treatment authorization has been denied, you should read the notice carefully. You or your health care provider might be able request a review of the denial and will be able to present evidence to the Board, who will determine whether the treatment should be authorized.
Independent Medical Examination (IME)
- The insurer has the right to ask you to be seen by an independent medical examiner.
- You should receive notice that an independent medical examination has been scheduled at least seven business days before the exam is supposed to happen.
- The examination may be videotaped by you, or by the examiner. If the examiner wants to videotape the exam, they must tell you that they are doing so.
- You are allowed to bring someone else with you to the exam.
- The examination should happen during regular business hours, unless you agree to a different time, and should be reasonably close to your home.
- The report that follows the examination may be used when determining the degree of your disability and could affect your benefits.
Sometimes you need help getting back to work. Your employer may have alternative or light duty assignments that enable you to work while you heal. An injury can also cause family or financial problems. The Board has vocational rehabilitation counselors and social workers to help.
Contact the Board
Customer Service Toll-Free Number: (877) 632-4996
Monday through Friday - 8:30 a.m. to 4:30 p.m.
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