Explanation of Benefits
Information Applies to Utah Claims
Medical benefits are provided for reasonable and necessary medical care that is related to the work-related accident or illness. Some of the covered benefits include office visits, chiropractic care, dental care, prescription medications, surgical care and durable medical equipment. Except for hospitals, payments are made according to Utah's fee schedule.
Many procedures and treatment programs, including but not limited to surgeries, chiropractic care and physical therapy, must be pre-authorized by WCF Insurance to be covered. Explanation of what medical treatments need to be pre-authorized and how to seek authorization.
Preferred Provider Organization
WCF Insurance has an agreement with a network of hospital and physicians that offer quality care at discounted rates. Our PPO consists of any WorkMed clinic, any IHC facility and University of Utah Medical Center. For a list of approved providers click here.
WCF Insurance provides a prescription card with Pharmacy Benefit Management for injured workers to use to obtain medications related to their claim. This allows the pharmacy to bill WCF Insurance directly with no out-of-pocket expense to the injured employee.
Injured workers are entitled to change physicians one time without prior authorization from WCF Insurance or the Labor Commission. Changing from an emergency room is not counted as a change, nor are referrals from a treating physician.
Emergency Room Treatment
Once treatment with a physician is established, emergency room visits are prohibited under Utah Labor Commission Rule R612-2-9. This rule does not apply to cases of threat to life or limb and /or direct referral from a treating physician. Injured workers who fail to comply with this rule will be held responsible for all charges associated with the emergency room care.
Generally, WCF Insurance will not pay for similar treatment from more than one medical provider. However, under certain circumstances, it may be authorized. Please contact the claims adjuster for pre-authorization.
Receiving Treatment Outside of Utah
Medical treatment outside of Utah will be paid according to Utah's fee schedule. However, any balance will be the injured workers responsibility.
Managed Care Programs
WCF Insurance strives to provide injured workers with quality medical care, by using managed care. The following programs have been implemented for your benefit:
Provider Bill Review
WCF Insurance reviews every medical bill to ensure appropriate codes are used for the service rendered and payments are made according to the Utah Labor Commission's fee schedule. Trainings are also conducted within the medical community on correct billing procedures.
Preferred Provider Organization (PPO)
WCF Insurance has an agreement with a network of hospitals and physicians that offer quality care at discounted rates. Utah law requires injured workers to use established PPO as long as they have been notified of the program. If the injured worker chooses not to use the PPO facilities, he or she may be required to pay any excess fees charged by the provider. A listing of all PPO physicians, facilities and hospitals is available by clicking here or by calling our Claims Department at 385.351.8010.
In-patient hospitalizations and many outpatient procedures are pre-authorized through our Utilization Review Department. Registered nurses and physician consultants provide prospective and retrospective reviews of medical treatment.
Medical Case Management
Medical case managers provide onsite evaluation of the injured worker's situation and coordinate with health care providers to facilitate recovery and return to work. WCF Insurance also has a specialized team to monitor injured workers with catastrophic injuries. All WCF Insurance medical case managers are registered nurses with specialty certifications in case management and rehabilitation.
Vocational Rehabilitation counselors help return injured employees return to work in a timely manner. Counselors coordinate with employers and physicians to verify work capabilities, assist with job modifications or facilitate other employment options or retraining for injured employees. They can also assist employers in developing their own return to work programs.
Injured workers are paid lost wage compensation when a physician says they are unable to work because of a work-related accident or illness and provides the appropriate documentation.
Lost wage compensation amounts are based on a percentage of the injured worker’s average weekly wage at the time of the injury. If the injured worker is off work 14 days or less, there is no lost wage compensation paid for the first three days after the date of injury. If the injured worker is unable to work 15 or more days, lost wage compensation begins the day after the injury.
Types of Lost Wage Compensation
Temporary Total Disability (TTD)
TTD is paid when the injured worker is temporarily unable to work in any capacity. Lost wage compensation is 2/3 of the average weekly wage at the time of the injury plus dependent allowance. TTD is paid every 14 days.
Temporary Partial Disability (TPD)
TPD is paid when the injured worker is temporarily working reduced hours or at a reduced rate of pay because of the injury or illness. Lost wage compensation is 2/3 of the difference between the average weekly wage at the time of the injury and the current weekly wage plus dependent allowance. TPD is paid every 14 days.
TTD and TPD payments continue until the injured worker is released to return to work full duty or until they reach maximum medical improvement or medical stability. If the physician reports that the injured worker may work with certain limitations, and if the employer is able to provide full-time modified duty within these limitations, the injured worker will not be entitled to temporary disability compensation.
Permanent Partial Disability (PPD)
PPD is paid when the injured worker’s accident or illness causes a permanent impairment, generally a loss of physical function. The treating physician should determine the percentage of impairment after the injured worker has reached maximum medical improvement or medical stability. PPD is paid every 28 days or is available in a lump sum.
Permanent Total Disability (PTD)
PTD is paid if the injured worker is permanently disabled from performing any type of gainful employment. Lost wage compensation is 2/3 of the average weekly wage plus dependent allowance up to the maximum set by law. PTD is paid every 28 days.
If an employee dies because of a work-related injury or disease, workers compensation insurance pays the following:
- Burial expenses up to $8,000
- Lost wage compensation to the spouse and dependent children. Compensation is based upon the employee's average weekly wage subject to minimum and maximum amounts. Benefits are available to the spouse until they remarry. Dependent children continue to receive benefits until they reach age 18.