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Reporting a Claim to Sedgwick (Article)

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NAVIGATOR CASUALTY, LTD.


Reporting a claim to Sedgwick

We know how important it is for you to report your claims simple and fast, and we’ve made claims reporting quick and easy with multiple options: online reporting through our intake platform, smart.ly; a single dedicated clinical consultation phone number; and email reporting. All three of these options are available for new claim intake 24 hours a day, seven days a week.


Always be sure to include the Navigator contract number 7130, member name, member ID, member location address and loss location address so that the claim can be assigned to the correct location. If this is not included the claim process can be delayed. If you do not know your member number, contact Laura Van Remortel, Shawn Brend or Jennifer Bolger.

Clinical consultation: Call 866-686-0405

Report by phone using our blended intake system utilizing our Clinical Consultation services. This is a 24/7 nurse line for non-urgent workplace injuries. By connecting with a Sedgwick certified nurse, they can provide an immediate medical assessment and recommendations on if a claim should be created. Depending on jurisdiction they may also be able to help schedule an appointment during the call. They will then send all of the claim information to our intake system to have the claim created. Please note there is an additional fee of $110 to use this service if a claim is created.

Crisis care hotline: 1-800-325-9507

When a catastrophic event happens in the workplace, it is difficult to know how to help and where to turn. Sedgwick’s crisis care program provides 24/7 resources to assist employers and claims professionals with violent workplace events, catastrophic injuries and complex clinical situations. This number can be used out of business hours and can expedite the process of claims handling for an additional fee.

Online reporting

Smart.ly is our system that allows you to report claims online. This is the most efficient and accurate way of reporting as all data is uploaded automatically. All questions are laid out and go in a step-by-step order walking you through the claim process. Once the intake form is complete a first notice of loss will be created within a few hours and sent to those listed on the distribution list. If needing to speak to a nurse, click here.

Once your account is activated, it will automatically disable after 90 days of inactivity. To keep your account enabled, please log in within this time frame even if you do not have a claim to report.

Email reporting

Email reporting is also available but not recommended as this process is manual and can take 24 to 48 hours for a claim to be filed. The Navigator intake form must be filled out and can be emailed to 7130Navigator@Sedgwick.com.

Below are the intake forms you can use for emailing new claims. Also attached is an auto accident reporting guide for you to print and place in your company vehicles. This document will assist your drivers to collect pertinent information if an accident does occur.

Workers’ compensation intake form

Auto liability intake form

General liability intake form

Auto accident report guide

Claims process

Telephonic and online reporting options enable the member to receive a claim number and copy of the initial claim reporting form almost instantly, if requested. For escalation purposes, it is highly recommended that ALL catastrophic claims be reported telephonically. We also encourage you to also contact your client services director in advance. If a member reports the claim as ‘incident or record only’, this must be indicated in the “Accident Description.” Sedgwick team leads have the discretion to determine if a claim is an incident/record only, medical-only or indemnity.

Claim type definitions

Incident only: Report or record only - no medical sought, no investigation to be completed. No contacts are made.

Medical only: Medical only care - No lost time from work. Only employer & medical provider are contacted. The employee is not contacted by the examiner, instead they receive an automatic text message when the claim is created. If the employee wishes to contact their examiner, they can do so by replying to the text, texting the examiner through the mySedgwick app or calling the examiner using the Navigator Directory located on the Navigator landing page.

Indemnity claims: Lost time from work, questionable, greater than $5,000 in reserves, medical and/or impairment payments. Employer, medical provider & employee are contacted within one business day.

*Important information must be sent directly to the handling examiner once identified.

  • Members should not attach important/sensitive information when submitting the claim to the call center.
  • A Sedgwick office directory can be found on the Navigator landing page.

Initial investigation on indemnity claims

Sedgwick requires examiners to initiate contacts within one business day of receipt of the claim, with follow-up calls during initial five business days until contact is established. Please note if the claim is not filed under the correct location the claim process may be delayed.

Member – What can you do to help?

  • Set with the employee expectations of collaboration with Sedgwick throughout the life of the claim.
  • Ensure the employee has received their Welcome Packet and has signed up for mySedgwick to have direct access to their claim.
  • Direct initial care even before reporting the claim by reaching out to your preferred provider in advance if the state jurisdiction allows.
  • Prepare and complete your company internal investigation. Be sure to have all relevant details available at the time of initial contact such as third-party/witness information, job descriptions, ability to accommodate restrictions and wages.

Compensability

All states require Sedgwick as the third-party administrator to render a compensability decision mostly within 14 calendar days for the workers' compensation claim being reported to the employer. If this decision must be delayed, Sedgwick must report any and all reasons or barriers to support this delay with the state. The examiner can discuss jurisdictional exceptions, SIU options and details with you. Please allow the examiner time to complete their investigation and provide all documentation that the examiner requests in a timely manner.

Directing medical care

Processing medical treatment must be supported by dictation and related to the injury or loss. Sedgwick does not own nor control doctor’s offices, physical therapists, pharmacies and other ancillary services. There are certain states where an employer can direct care, and this is encouraged if you have preferred providers. Check the Medical Provider Tool (MPN) to see if the provider is in network to get additional savings. If you need additional assistance with navigating the MPN, click here.

Telephonic / Field Nurse Case Managers (WC): Under the authorization of the member, examiners are able to assign a nurse to the claim to assist injured employees, including attendance at office visits, and ensure treatment is appropriate for the injuries, and is progressing as expected. This service allows a certified nurse access to the file and to the employee to allow for greater communication and assistance with treatment.

Utilization review (UR): This process requires prior authorization by assessing medical necessity of recommended treatment. UR nurses have strict time frames for reviewing the requests which varies by state. Mandatory UR states are AL, CA, KY, LA, MA, MS, NY, TN, TX.

Provider search tool: All members have access to Sedgwick's panel of providers. This access gives employers the ability to direct initial care (if jurisdiction allows) and also create customized panels adhering to jurisdictional requirements, assisting employers and adjusters in finding the best doctors in any given area to refer their employees. The following states require all employers to visibly post the panel of physicians in a common area: CO, GA, PA, TN, VA. To access Sedgwick’s Provider Search Tool, please use the following:

Site: https://www-sf.talispoint.com/sedgwick/login/
Username: Sedgwick7130
Password: 7130

Member – What can you do to help?

  • As an employer, you are expected to direct initial care of your injured employee if jurisdiction allows.
  • For any delays in care, please contact the team leader found on the office directory immediately.
  • Always provide the employee with Sedgwick billing information when directing them to initial care. Ensure they have access to the First Fill card for their first prescription.
  • Use Medical CARD for initial providers account setup.

Litigation

Sedgwick will notify you if a letter of representation is received and/or litigation. The carrier Arch dictates the usage of defense attorneys based on a preapproved panel. Once the attorney is assigned; the examiner and defense attorney will work with you to develop a legal strategy and develop a resolution. Carrier has negotiated special rates for their services. You can also be updated when an attorney is assigned by setting up an alert in viaOne.

Member – What can you do to help?

  • Advise your examiner if you receive a notice of representation or any litigation documents.
  • Assignment of counsel must be selected from carrier’s approved panel list. If an outside counsel is requested, prior approval must be obtained in advance and at the discretion of the carrier. Sedgwick does not control this process.
  • At any time, you can always request a strategy conference call with your examiner and defense counsel.

Lost time

Benefits are administered in accordance with jurisdictional guidelines as defined by the workers' compensation law. Timely initiation of benefits cannot be delayed pending receipt of wage statement from employer. The claims examiner will estimate the benefits due based on facts known at the time. Sedgwick will file all state forms as required accordingly. Salary should not be paid in lieu of lost time benefits, but if you elect to pay, be sure to have a salary continuation program requested as soon as possible.

Member – What can you do to help?

  • Transitional return to work programs are available to help the employer if light duty restrictions cannot be accommodated. Examiner can coordinate transitional employment with nonprofit agencies.
  • Talk with your examiner to see if telephonic or field case management could be beneficial for the claim to ensure the employee has as much support as possible to schedule appointments, direct care, get restrictions letters and ensure that care is being driven efficiently.

viaOne

https://viaonenew.sedgwickcms.net/
Assistance: 866-647-7610

This system grants you access to all of your claim information. After a claim has been submitted, you can use ViaOne to review claim activity, financials and examiner notes throughout the life of the claim. ViaOne is real time and available 24/7. viaOne can also be used to run a variety of reports, loss runs and to set up alerts for specific criteria that you may want to keep a close eye on, such as when a claim is entered in our system, when an examiner changes, among other things. In addition, you can use ViaOne to set diaries for yourself.

Member – What can you do to help?

  • Review the basic guide to viaOne on the Navigator landing page.
  • Attend live training seminars located on the viaOne home page under announcements.
  • If you have a unique need or a certain type of data request reach out to the client services director at Sedgwick to schedule a one-on-one training with the viaOne training team.

Closure of claim

A denied claim should remain open for 30 days or as required by the jurisdiction for a potential contest to the denial. An accepted claim should be reviewed to ensure all open items have been resolved prior to closure.