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Medical Treatment and Billing The Pool contracts with the Political SubdivisionWorkers’ Compensation Alliance, “the Alliance,”to provide medical treatment for injured workersusing evidence-based medicine for the best possiblereturn-to-work outcomes. When a memberparticipates in the Alliance, there is a 4% discounton workers’ compensation coverage, and the injuredworker is responsible for choosing a treating doctorfrom a list of doctors on the Alliance website atwww.pswca.org. Alliance instructions, a posting andan employee acknowledgement are contained in thisguide. In order to avoid confusion and prevent the claimfrom being filed with your healthcare insurancecompany, the injured worker can provide the“Notification of WC Coverage Provider” to his orher medical provider at the time of treatment. Modified Duty andReturn-to-Work ProceduresWhen an injured worker is released to light or modifiedduty with restrictions, the member should make everyattempt reasonably possible to provide modified work.Assistance with finding modified jobs within the countyis available through the Pool’s Risk Control Consultants.If a member chooses not to participate in theAlliance, the injured worker may choose any doctornot barred by the Division of Workers’Compensation from treating injured workers. We ask that you provide the treating doctor withfunctional temporary job descriptions (DWC-74:Description of Injured Employee’s Employment)and work with the adjusters, treating doctors andinjured workers concerning available return-to-workoptions. Treating doctors are responsible for schedulingappointments, ordering tests, providing treatment,making referrals, sending required medical reports(DWC-73: Texas Workers’ Compensation WorkStatus Report) and addressing the injured worker’sability to work. Please note, the workers'compensation law prohibits the Pool fromdirecting medical treatment.Revised April 2020All medical bills pertaining to the work-relatedinjury should be sent from the medical providerdirectly to the Pool’s third party administrator,Sedgwick, for processing. Please ensure theinjured worker presents the Notification of WCCoverage Provider when attending the initialmedical appointment. This will prevent themedical provider from erroneously billing ahealthcare PPO. PPOs will not release medicalrecords without a signed medical authorizationfrom the injured worker. This can delaytreatment and inhibits medical management ofthe claim.A sample Bona Fide Offer of Employment in thispacket complies with the requirements stipulated inDWC Rule §129.6. Before an employee returns towork on modified duty, please extend this offer andattach the DWC-73: Work Status Report. Each offermust comply with the doctor’s restrictions. A BonaFide Offer of Employment documents the acceptanceor refusal of the modified work. Failure to use the offercan result in the injured worker receiving TemporaryIncome Benefits when modified duty is readilyavailable at the county. For more information onReturn to Work, request a copy of the TAC RMPReturn to Work Resource Guide.Questions?As always, we appreciate the opportunity to serve Texascounties and related districts. Should you have anyquestions or suggestions concerning this document orclaims reporting, please contact Stacy Corluccio,Claims Manager, at StacyC@county.org or (512)478-8753, ext. 3634.3

SedgwickTAC RMP - Dedicated UnitP.O. Box 160120Austin, TX 78716(800) 752-6301*(512) 346-9321 - fax*dial 1 last 4 digits for extensionLeticia NavarroSenior WC Manager - Teamleticia.navarro@sedgwick.com(512) 427-2415Lezlie McNew, AICMary Rankin-RNSenior WC Manager - Unitlezlie.mcnew@sedgwick.com(512) 427-2328Lidisbet RiveroBSHCM, CCMMedical Case ManagerMary.Rankin@sedgwick.com(203) 702-4283(201) 559-4433 - faxCorrie ChapmanDesirina GonzalesWC Claim Examiner IIlidisbet.rivero@sedgwick.com(512) 427-2446Senior WC Claim Examiner - Complexcorrie.chapman@sedgwick.com(512) 427-2315WC Claims Examiner IIdesirina.gonzales@sedgwick.com(512) 427-2367Alicia FaulstichCleo FredricksLatoya JoynerWC Claims Examiner IIAlicia.faulstich@sedgwick.com(512) 427-2318WC Claims Examiner Icleo.fredricks@sedgwick.com(512) 427-2335Kathryn StevensWC Claims Examiner ILatoya.joyner@sedgwick.com(512) 427-2408Dedicated Email:WC Claims AssociateKathryn.stevens@sedgwick.com(512) 427-2354New claims, correspondence, documentsUS-YORK-tacdwcforms@sedgwick.comClaims Administrator, SedgwickP.O. Box 160120 Austin, TX 78716 800-752-6301 FAX 512-346-9321

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Texas Association of CountiesRisk Management PoolP.O. Box 160120Austin, TX(800) 752-6301Texas Association of Counties Risk Management PoolWorkers’ Compensation Prescription InformationEmployer:Please fill out employee information below and provide employee with this document to take to any pharmacy with prescriptions.Employee Name:Group#:Member ID (SSN):Date of Injury:Processor:Bin#:10602730myMatrixx014211Day supply is limited up to 30 days for a new injury.myMatrixx Help Desk: (877) s Association of Counties Risk Management Pool has partnered with myMatrixx to make filling workers’ compensationprescriptions easy.This document serves as a temporary prescription card. A permanent prescription card specific to your injury will be forwardeddirectly to you within the next 3 to 5 business days. This form does not certify compensability or guarantee payment.Please take this letter and your prescription(s) to a pharmacy near you. myMatrixx has a network of over 4,680 pharmacies inTexas and 65,000 pharmacies nationwide. If you need assistance locating a network pharmacy near you, please call myMatrixxtoll free at (877) 804-4900, or you can visit www.mymatrixx.com.TO LOCATE AN APPROVED DOCTOR OR HEALTHCARE PROVIDER, PLEASE VISIT:WWW.PSWCA.ORGIF YOU ARE DENIED MEDICATION(S) AT THE PHARMACY PLEASE CALL (877) 804-4900Pharmacist:Please obtain above information from the injured employee if not already filled in by employer to process prescriptions for theworkers’ compensation injury only.For questions or rejections please call (877) 804-4900. Please do not send patient home or have patient pay for medication(s)before calling myMatrixx for assistance.FOR ALL REJECTIONS OR QUESTIONS CALL: (877) 804-49006

Find a ProviderProvider ManualBoard Meeting ScheduleProvider ApplicationInjured WorkersMain Office: 512-220-1770ProvidersAbout the AllianceToll Free: 866-997-7922ContactEmailFIND A PROVIDERServing Public ServantsOur members are known for their service to their localcommunities—at city hall, the county courthouse, in schools,community centers, public utility facilities, and as firstresponders. If they get hurt on the job, the Alliance is here tomake sure these dedicated public servants have access totop quality health care providers. We exclusively serve themembers of five (5) public entity risk pools.Injured WorkersProvidersFind a providerFrequently asked questionsFrequently asked questionsProvider applicationContact your adjusterFormsThe Political Subdivision Workers' Compensation Alliance (the Alliance) is a 504 network serving 5 public entity risk pools:7http://www.pswca.org/[1/12/2016 2:54:21 PM]

IMPORTANT INFORMATION REGARDINGPOLITICAL SUBDIVISION WORKERS COMPENSATION ALLIANCEDO NOT DISCARD!We are pleased that you have elected to utilize medical providers contracted by the thePolitical Subdivision Workers’ Compensation Alliance (Alliance) to treat your injuredworkers. We have enclosed all the information you will need in order to start using thisprogram.General Instructions for Employers1. Employee NotificationAs a participating employer, you are responsible for notifying your employees aboutthe requirement to use health care providers that are under contract with the Alliance.This can be accomplished by providing your employees a copy of the “Employee Noticeof Political Subdivision Workers Compensation Alliance (Alliance) ProgramRequirements.” A sample notice is enclosed and is also available online atwww.county.org. Notice must be distributed to all employees and should be includedin any new hire paperwork or during orientation.2. Posting NotificationIn addition to providing notice to each individual employee, the posting in this guideshould be posted at each of your locations along with your other required postings.3. Employee Signed Acknowledgement of NoticeEach employee must sign the “Employee Acknowledgment of the AllianceDirect Contracting Program” form that is included with the notice. Thefollowing steps below are suggested to facilitate the notice process:8

i.Provide a copy or email the notice and acknowledgement form toall employees. You may distribute the notice andacknowledgement in a manner that is more electronicallyconvenient, such as use of an intranet.ii.Ask all employees to complete and return the acknowledgementform within a specific time frame (we suggest 7 days).iii.If the notice will be distributed at a scheduled staff meeting orsafety meeting and the signed acknowledgement forms will also becollected, have witnesses available should any employee refuse tosign the form.iv.New employees should receive the notice and return a signedacknowledgement as part of their “new hire” process.9

DocumentationEstablish a standardized process as indicated above for delivery of notice andacknowledgement form that includes documenting: The method of notice delivery To whom the notice was delivered The location of the delivery The date deliveredPlease retain copies of the signed acknowledgement form(s) in each employee’spersonnel file. An employee who refuses to sign is still subject to direct contractingrequirements. All refusals should be documented in the employee’s personnel file.Please do not return the signed forms to The Texas Association of Counties RiskManagement Pool unless it is requested by an adjuster.What to Do When an Injury OccursIf appropriate, provide or arrange transportation for the injured employee to acontracted Alliance provider or, if necessary, to the nearest emergency facility.As a reminder to the employee, you should provide the Employee Notice of PoliticalSubdivision Workers Compensation Alliance (Alliance) Program Requirements (a copy isenclosed) to the injured employee at the time the injury is reported to you, or as soon aspractical thereafter. The injured employee will need to sign the acknowledgementpage. Please keep a copy of the signed form in your records. If necessary, your adjusterwill request a copy from you.Otherwise, you will continue with your usual procedure with regards to reportingwork-related injuries. Remind the injured employee of the need to use Allianceproviders and advise them how to locate a provider. You can search a list of the directcontract providers from the Alliance website at www.pswca.org. If you do not haveaccess to the internet, please contact your adjuster at 800-752-6301 for a list of providersin your area.10

11Rev. 08/16You may contact your adjuster at the TAC Risk Management Fund at 800-752-6301.When you are injured, you may locate a medical provider on line at www.pswca.org.Tell your supervisor or employer immediately. For emergencies, you may go to the nearestemergency room. Otherwise, you must choose a treating doctor from the list on the website below. Your employer will assist with any questions about how to obtain treatment.You may also contact your adjuster at the Texas Association of Counties (TAC) for anyquestions about treatment for a work related injury. The TAC Risk Management Fund isyour employer’s workers’ compensation coverage provider. They work with your employerto ensure you receive timely health care. The goal is to return you to work as soon as it issafe to do so.When you are injured at work .Your employer has chosen the Political Subdivision Workers’ Compensation Alliance (theAlliance) to manage the health care and treatment you may receive if you are injured atwork. The Alliance includes a list of health care providers who are trained in treating workrelated injuries and getting people back to work safely.Dear Employee:NOTICE OF POLITICAL SUBDIVISION WORKERS’ COMPENSATIONALLIANCE REQUIREMENTS FOR WORK RELATED INJURIES

NOTE: This is a sample document. TAC will provide an electronic copy for your use upon request.Employee Notice ofPolitical Subdivision Workers Compensation AllianceProgram RequirementsImportant Contact Information Alliance website is www.pswca.org Alliance phone number is 1-866-997-7922 To contact your adjuster call 1-800-752-6301Information, Instructions and your Rights and ObligationsAs your employer, insert employer name , has elected to utilizethe Political Subdivision Workers Compensation Alliance (Alliance) to provide access tocontracted physicians and healthcare providers for workers’ compensation injuries.If you are injured at work, tell your supervisor or manager immediately. The enclosedinformation will help you seek care for your injury. Also, your employer will help withany questions about how to get treatment. You may also contact The Texas Associationof Counties Risk Management Pool Workers’ Compensation Claims Department at 1800-752-6301 for any questions about your care and treatment for a work related injury.TACRMP and your employer have formed a team to provide you with timely care andtreatment for work related injuries. The goal is to provide quality medical care andreturn you to work as soon as it is safe to do so.Injured Employees Rights and ObligationsWhat to do if you are injured while on the job:If you are injured while on the job, tell your employer as soon as possible. A list ofAlliance treating physicians may be available from your employer. A complete list isalso available online at www.pswca.org or you may contact your adjuster directly at thefollowing address and telephone number:Texas Association of Counties Risk Management PoolP.O. Box 160120Austin, TX 787161-800-752-630112

In case of an emergencyIf you are hurt at work, you should first notify your employer and they will assist youin locating a provider or emergency care provider.After you receive emergency care or treatment, you may require ongoing care. Youwill need to select a treating doctor from the Alliance provider list. This list isavailable at www.pswca.org. If you do not have internet access, please call1-800-752-6301 or contact your employer for a complete listing. The doctor youchoose will oversee the care you receive for your work-related injury. Except foremergency care, you must obtain all health care and specialist referrals through yourtreating doctor.Choosing a Treating DoctorIf you are injured at work you must choose a treating doctor from the Alliance panel ofproviders. This is REQUIRED for the cost of your medical care for your work relatedinjury to be covered. A provider listing is available through the Alliance website atwww.pswca.org. It is updated weekly and identifies providers who are contracted withthe Alliance and accept workers’ compensation patients.If your treating physician leaves the Alliance you will be notified and you will have theright to choose another treating doctor from the list of providers. If your doctor leavesthe Alliance and you suffer a life threatening or acute condition for which a disruptionof care would be harmful, your doctor will contact your adjuster to request that youtreat with him/her for an additional 90 days.Changing DoctorsIf you become dissatisfied with your initial choice of treating physician, you cancomplete the Change of Treating Doctor Form to select a new treating doctor from the listof Alliance providers. This form is available at www.county.org and should becompleted and submitted to your adjuster for approval prior to changing doctors.ReferralsReferrals are not required for emergency care. Your treating doctor will refer you toother health care providers if necessary for your medical treatment.13

Payments for Health CareAlliance providers have agreed to bill TACRMP for payment in relation to your healthcare. You should not be required to make payment at the time of your treatment. Youmay only access non-Alliance health care providers and remain eligible for coverage ofyour medical costs if one of the following situations occur: Emergency care is needed. You should go to the nearest hospital, urgent care, oremergency care facility You do not live within 75 miles of a contracted provider Your treating physician refers you to a non-Alliance provider or facility ANDyour adjuster has approved the referral prior to treatment.Non-emergency careOnce you have selected your treating physician, your adjuster will be notified and theywill contact you if additional information is required.ComplaintsYou have the right to file a complaint with the Alliance. You may do this if you aredissatisfied with any aspect of the operation. This includes a complaint about theAlliance or an Alliance treating physician or facility. It may also be a general complaintabout the PSWCA Direct Contracting Program.Complaints should be addressed to the PSWCA Direct Contracting Program GrievanceCoordinator by phone or in writing via email or fax. Complaints should be sent to:PSWCA Direct Contracting ProgramAttention: Grievance CoordinatorP.O. Box 763Austin, TX 787671-866-997-7922customerservice@pswca.org14

Employee Acknowledgement of PSWCA Direct Contracting ProgramI have received information that informs me of my employer’s election to utilize thePolitical Subdivision Workers Compensation Alliance (Alliance) and how to obtainhealth care if I should suffer a work related injury/illness.If I am injured on the job, I understand that:1. I must choose a treating doctor from the list of contracted providers provided bymy employer or obtain the list myself from www.pswca.org2. I must go to my treating doctor for all health care related to my injury. If I need aspecialist, my treating doctor will refer me. If I require emergency care I may goanywhere.3. Making a false of fraudulent workers’ compensation claim is a crime that mayresult in fines and/or imprisonment.4. Additional information regarding the Alliance is available on TACRMP’s websiteat www.county.orgSignatureDatePrinted NameI live atStreet AddressCity, State, Zip CodeName of EmployerPlease indicate whether this is the:Initial Employee NotificationDate of Injury Notification (date of injury / / )PLEASE RETURN THIS FORM TO YOUR EMPLOYER15

Employer Rights and ResponsibilitiesInformation for Employers from the Division of Workers’ Compensation the right to report suspected fraud to the TDI-DWCor to the insurance carrier; the right to contest the failure of the insurancecarrier to provide required accident preventionservices; and the right to receive return-to-work coordinationservices as necessary to facilitate an employee’sreturn to employment.To dispute a workers’ compensation claim, an employermay file the DWC Form-004, and the DWC Form-045,Request to Schedule, Reschedule or Cancel a BenefitReview Conference (BRC), which may be obtained fromthe TDI website at http://www.tdi.texas.gov/forms/form20employer.html or by calling 1-800-252-7031.Workers’ Compensation Insurance CoverageWorkers’ compensation insurance coverage providescovered employees with income and medical benefits ifthey sustain a work-related injury or illness. Except asotherwise provided by law; Texas private employers canchoose whether or not to provide workers’ compensationinsurance coverage for their employees. Except in casesof gross negligence or an intentional act or omission ofthe employer, workers’ compensation insurance limits anemployer’s liabili

Workers' Compensation Performance- Based Oversight Audit process and is there to facilitate the claims process for you. In tandem, Sedgwick and the Pool strive to provide an easy claims reporting experience. Our goal is to ensure complete member compliance with the Texas Workers' Compensation Act. This resource guide will assist in this .