Claims Kit - ProSight Specialty Insurance

WORKERS’ COMPENSATION
Claims Kit
Dear Customer,
Thank you for choosing ProSight Specialty Insurance as your Workers’ Compensation
Insurance carrier. We pride ourselves on providing excellent service and will do our
very best to meet your Workers Compensation Claims needs.
ProSight Specialty Insurance writes our Workers’ Compensation policies through our
New York Marine and General Insurance Company underwriting company, which is
the name you will see listed on your policy.
ProSight has partnered with a leading Workers’ Compensation claims service provider,
Gallagher Bassett Services, to assist us in the administration of claims. Gallagher
Bassett will be your primary point of contact for claims. To determine which office will
be handling your claims, please refer to the map included with this packet.
Please make sure to include your Policy Number on all correspondence.
For your convenience, the following documents can be found inside your claims kit:
•
•
•
•
•
•
Instructions on how to report a claim
Claim Handling Map
List of Claim office locations, mailing addresses, and claim contacts
How to locate a Physician
Pharmacy cards
Links to your state’s Workers’ Compensation forms and Web Pages
Please do not hesitate to contact us should you have any questions or concerns.
Workers’ Compensation Claims Department
ProSight Specialty Insurance
412 Mt. Kemble Avenue
Morristown, NJ 07960
claimsinquiry@prosightspecialty.com
Phone: 800-774-2755
Fax: 855-657-3534
Need to Report a Claim?
By e-mail:
claims@prosightspecialty.com
By phone:
(800)-774-2755
Press ‘1’ to report a claim
(Available anytime- days, nights & weekends)
Press ‘2’ to inquire about a claim
(Available 8:00am to 5:00pm EST)
By fax:
(800)-326-2864
By Mail:
ProSight Specialty Insurance Claims Department
412 Mt. Kemble Avenue
Suite 300C
Morristown, NJ 07960
Additional Instructions:
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EXPERIENCED PROFESSIONALS.
INSIGHTFUL SOLUTIONS.SM
Workers’ Compensation Claim Handling
Washington
Montana
New Hampshire
Vermont
North Dakota
Maine
Minnesota
Oregon
South Dakota
Idaho
Nebraska
Pennsylvania
Iowa
Illinois
Utah
Colorado
California
New York
Kansas
Indiana
Ohio
Oklahoma
New Mexico
New Jersey
Delaware
Maryland
West
VirginiaVirginia
Missouri
Kentucky
Arizona
Rhode
Island
Connecticut
Michigan
Wyoming
Nevada
Massachusetts
Wisconsin
North
Carolina
Tennessee
South
Carolina
Arkansas
Mississippi
Alabama
Georgia
Texas
Louisiana
Alaska
Hawaii
ProSight Specialty Insurance
Florida
Gallagher Bassett Services
LWP Claims Solutions
Monopolistic
Claims Handling Offices | ProSight Specialty Insurance
Mailing
Workers’ Compensation Claims Department
ProSight Specialty Insurance
412 Mt. Kemble Avenue
Morristown, NJ 07960
claimsinquiry@prosightspecialty.com
Phone: 800-774-2755
Fax: 855-657-3534
Contacts
WC Claims Manager: Melissa Kovacsy
mkovacsy@prosightspecialty.com
Lost Time Adjuster: Patrick Gano
pgano@prosightspecialty.com
Medical Only Adjuster: Melinda Bullock
mbullock@prosightspecialty.com
Alabama
Arkansas
California
Colorado
Connecticut
Delaware
DC
Florida
Georgia
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maryland
Massachusetts
Michigan
Minnesota
Missippi
Missouri
Nebraska
New Hampshire
New Jersey
New York
North Carolina
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Utah
Vermont
Virginia
West Virginia
Wisconsin
Claims Handling Offices | Alaska
Mailing
Wilton Adjustment Service, Inc. – 425
625 E. 34th Avenue, Suite 400
Anchorage, AK 99503
Phone: 907-276-3311
Fax: 907-276-7877
Contacts
Branch Manager: Joanne Pride, x 3412
joanne-pride@wiltonalaska.com
Adjuster: McKenna Wentworth, x 3452
mckenna-wentworth@wiltonalaska.com
Medical Only: Shea Loescher, x 3317
shea-loescher@wiltonalaska.com
Alaska
Claims Handling Offices | Arizona
Mailing
Gallagher Bassett Services- 007 (Phoenix)
PO Box 10849
Scottsdale, Arizona 85271
Phone: 480-586-9500
Fax: 480-443-8416
Toll Free: 800-231-3759
Contacts
Branch Manager: Bruce Martin
Bruce_martin@gbtpa.com
Arizona
Claims Handling Offices | Hawaii
Mailing
Gallagher Bassett Services -162
900 Fort Street, Suite 420
Honolulu, HI 96813-4511
Phone: 808-532-7362
Fax: 808-545-5967
Toll Free: 877-492-9645
Contacts
Nadine Kurihara-Nakasu, Branch Manager
Nadine_Kurihara-Nakasu@gbtpa.com
Hawaii
Claims Handling Offices | Idaho
Mailing
Gallagher Bassett Services – 193
720 East Park Blvd., Suite 125
Boise, ID 83712
Phone: 208/345-8090
Fax: 208/345-3996
Toll Free: 866/217-1192
Contacts
Regina Pearson, Branch Manager
Regina_Pearson@gbtpa.com
Idaho
Claims Handling Offices | Montana
Mailing
Gallagher Bassett – 080 (Missoula)
2501 Catlin Street, Suite 200
Missoula, MT 59801
Phone: 855-335-7892
Fax: 406-721-2735
Contacts
Regina Pearson
208-515-3835
regina_pearson@gbtpa.com
Montana
Claims Handling Offices | Nevada
Mailing
Gallagher Bassett Services – 156
P.O. Box 70030
Las Vegas, NV 89170
Phone: 702-789-4500
Toll Free: 866-889-4755
Fax: 866-823-4130
Contacts
Charles Rostad, Branch Manager
Charles_Rostad@gbtpa.com
(UPS, Federal Express, etc)
2110 E. Flamingo Road, Suite 314
Las Vegas, NV 89119
Nevada
Claims Handling Offices | New Mexico
Mailing
Gallagher Bassett Services - 046
2424 Louisiana NE, Suite 220
Albuquerque, NM 87110
Phone: 505-837-2180
Fax: 505-837-2187
Toll Free: 866-859-2180
Contacts
Regina Pearson, Branch Manager
Regina_Pearson@gbtpa.com
New Mexico
Claims Handling Offices | Oklahoma
Mailing
Gallagher Bassett Services - 132
6303 Waterford Blvd., Suite 120
Oklahoma City, OK 73118
Phone: 405/843-7244
Fax: 405/843-8658
Toll Free: 800/943-7244
Contacts
Stacy Goble, Branch Manager
Stacy_Goble@gbtpa.com
Oklahoma
Claims Handling Offices | Oregon
Mailing
Gallagher Bassett Services – 155 (Portland)
4550 Kruse Way, Suite 155
Lake Oswego, OR 97035
Phone: 503-675-6575
Fax: 503-675-6574
Toll Free: 877-800-3059
Contacts
Eric Sorem, Branch Manager
Eric_Sorem@gbtpa.com
Oregon
Claims Handling Offices | Texas
Mailing
Gallagher Bassett Services - 025 (Dallas)
6404 International Parkway, Suite 2300
Plano, Texas 75093
Phone: 972-931-6277
Fax: 972-931-6256
Toll Free: 800-382-0166
Contacts
Terry Tarter, Branch Manager
Terry_Tarter@gbtpa.com
Texas
Navigating the Coventry Medical
Provider Directory Website
Use this search tool to locate Medical Providers
ONLY If your claims are administered by Gallagher Bassett
•
Go to www.firsthealth.com/welcome
•
Enter Login ID: GBMCS
•
A new page will appear, click on the link “Channeling Tools”
•
The next page will give you four options to choose from:
•
Address Search: This option is a radius search from a centralized address.
•
Name Search: Allows the user to look up a certain provider in the database by name or phone.
•
Region Search: This option allows the user to search in a specific region such as city, county, zip
code, etc.
•
Quick Search: A search using a limited number of specialties for providers who provide initial
treatment to a maximum radius of 35 miles around an address. Creates output to a custom
Worksite Poster or Directory.
•
Worksite Posters: This option allows the user to make a Worksite Poster with the closest network
providers while following all jurisdictional regulations and guidelines.
ADDRESS SEARCH
Begin by selecting the Network you wish to search. Enter your address. You must enter at least a valid ZIP
Code or a City/State combination. At the bottom of the page you may choose: Provider Types, Specialties
and/or distance. Once you click on “find providers” your results will be displayed.
NAME SEARCH
Use the Name Search tab if you already know a Provider’s name, group affiliation or phone
REGION SEARCH
Use this feature if you are searching for a provider in a specific area.
QUICK SEARCH
Use this tab if you are searching for ONLY one of the following: Family Practice, Internal Medicine,
Occupational Medicine, Emergency Medicine and Occupational Medical Clinics within 35 miles of a specific
address.
WORKSITE POSTER (WSP)
This page is used to create Worksite Posters or batches of Posters. For your convenience, you can upload
your Locations and create your posters!
Temporary Prescription Services ID
For Claims Administered by Gallagher Bassett
Attached you will find a prescription form (also called a temporary pharmacy
card) that must be given to each and every employee when there is an on the
job injury. Employees simply call the First Script number to locate a local
pharmacy where they can get their Workers Compensation prescription(s) filled.
It is a good idea to distribute these forms to your Supervisors, Team Leaders,
and your Human Resources department so they are familiar with the form.
Chances are they will receive the notices of injury and will likely be responsible
for handing the form to the injured employee.
PRESCRIPTION PROGRAM FOR WORK-RELATED INJURIES
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Dear Policyholder:
For your convenience, we have included the following website addresses to your state’s
Workers’ Compensation web page. From the links below, you can access any forms that
you might need when submitting a Workers’ Compensation claim.
Alabama
http://dir.alabama.gov
Kentucky
http://www.labor.ky.gov/
North Dakota
http://www.workforcesafety.com/
Alaska
http://www.labor.alaska.gov/wc/
Louisiana
http://www.laworks.net/
Ohio
http://www.ohiobwc.com/
Arizona
http://www.ica.state.az.us/
Maine
http://www.maine.gov/wcb/
Oklahoma
http://www.owcc.state.ok.us/
Arkansas
http://www.awcc.state.ar.us/
Maryland
http://www.wcc.state.md.us/
Oregon
http://www.cbs.state.or.us/wcd/
California
http://www.dir.ca.gov/dwc/
Massachusetts
http://www.state.ma.us/wcac/
Pennsylvania
http://www.portal.state.pa.us
Colorado
http://www.colorado.gov/
Michigan
http://www.michigan.gov/wca
Rhode Island
http://www.dlt.ri.gov/wc/
Connecticut
http://wcc.state.ct.us/
Minnesota
http://www.doli.state.mn.us/
South Carolina
Delaware
http://www.delawareworks.com/
Mississippi
http://www.mwcc.state.ms.us/
South Dakota
http://dlr.sd.gov/workerscomp/
DC
http://www.does.dc.gov/does/
Missouri
http://labor.mo.gov/
Tennessee
http://www.tn.gov/labor-wfd/
Florida
http://www.myfloridacfo.com/wc
Montana
http://erd.dli.mt.gov/
Texas
http://www.tdi.state.tx.us/forms/
Georgia
http://sbwc.georgia.gov/portal/
Nebraska
http://www.wcc.ne.gov
Utah
http://www.laborcommission.utah.gov/
Hawaii
http://hawaii.gov/labor/rs/
Nevada
http://dirweb.state.nv.us/WCS/wcs.htm
Vermont
http://www.labor.vermont.gov/
Idaho
http://www.iic.idaho.gov/
New Hampshire
http://www.labor.state.nh.us/
Virginia
http://www.vwc.state.va.us/portal/
Illinois
http://www.iwcc.il.gov/
New Jersey
http://lwd.state.nj.us/labor/wc/wc_index.html
Washington
http://www.lni.wa.gov/
Indiana
http://www.in.gov/wcb/
New Mexico
http://www.workerscomp.state.nm.us/
West Virginia
http://www.wvinsurance.gov/
Iowa
http://www.iowaworkforce.org
New York
www.wcb.state.ny.us
Wisconsin
http://dwd.wisconsin.gov/wc/
Kansas
http://www.dol.ks.gov/wc/about.html
North Carolina
http://www.ic.nc.gov/forms.html
Wyoming
http://doe.wyo.gov/aboutus/
http://www.wcc.sc.gov/Pages/default.aspx