Regulatory

California MPN workers' compensation resources for injured employees

• Complete written employee notification (English and Spanish)

• How to access the Sentry Insurance Group MPN (English and Spanish)

• Continuity of care policy (English and Spanish)

• Transfer of ongoing care policy (English and Spanish)

• Workers’ compensation notification pharmacy benefits network

Compensación para trabajadores recursos para empleados lesionados de la MPN de California

• Complete la notificación escrita para empleados (inglés y español)

• Cómo acceder a la MPN de Sentry Insurance Group (inglés y español)

• Política de continuidad de la atención (inglés y español)

• Transferencia de la política de atención continua (inglés y español)

• Red de beneficios de farmacia de notificación de compensación para trabajadores (inglés y español)

California MPN workers’ compensation resources for policyholders

As a brand of the Sentry Insurance Group, Hortica policyholders are automatically enrolled in the Sentry Insurance Group MPN #3197 unless they expressly opt out.

You must post these notices and forms in a conspicuous location frequently visited by the employees at each business location within the state, and/or printed and provided to the employee at the time of hire and/or at the time of injury.

Notice to employees—injuries caused by work (DWC-7)

You are required to post the DWC-7 in both English and Spanish in a location that’s clearly visible to employees in their workplace. This poster provides employees with information regarding workers’ compensation benefits and the California medical provider network (MPN). This must be posted in each of the employer’s California locations. Please complete the fillable fields with the information in the downloadable instructions.

View poster instructions

View poster—English and Spanish

Time of Hire Notice

Provide a Time of Hire Notice to all current employees if it wasn’t previously provided. You should also give the notice to new employees at the time they’re hired. The Time of Hire Notice provides employees with general information about workers’ compensation and the benefits available to injured workers. Please complete the fillable fields with the information in the Time of Hire instructions.

View Time of Hire instructions

View Time of Hire Notice—English

View Time of Hire Notice—Spanish

Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility

Provide the DWC-1 claim form to an employee upon notice of a claimed injury. This form initiates the claims process for the injured employee. You must complete this form within one working day of when you became aware of an employee’s work-related injury or illness. Submit a copy to the insurance carrier, provide a copy to the employee, and keep a copy for your own records.

View Workers’ Compensation Claim Form (DWC 1)

Employer’s report of occupational injury or illness (DLSR-5020)

You must complete this form within five days of being notified of a work-related injury or illness that results in lost time beyond the date of incident or requires treatment beyond first aid. Fatalities must be reported within 24 hours.

View Employer’s report of occupational injury or illness (DLSR-5020)

California pharmacy benefit network resources

Workers’ compensation notification pharmacy benefit network posters

Post these, along with the DWC-7 posters, in a location that’s clearly visible to employees in their workplace. These posters provide employees with information regarding the workers’ compensation pharmacy benefit network.

View poster—English

View poster—Spanish

Workers’ compensation notification pharmacy benefit network

Give this pamphlet to employees when they’re hired and when an injury occurs. It provides information on the pharmacy benefit network, information on locating participating pharmacies, and contact information if they have questions.

View pamphlet—English and Spanish

Pharmacy benefit network first fill card

Give this card to an injured employee at the time of injury or when the injury is reported to you. They’ll need to show this card to the pharmacy when obtaining prescriptions for their work-related injury. This is a temporary card; their permanent card will come in the mail. Using this card will allow initial prescriptions to be obtained at no cost to the injured employee.

View card—English and Spanish

Complete written employee notification

The complete employee notification doesn’t need to be posted in the workplace. We’ll send it to your employee when an injury is reported to us.

View notification—English

View notification—Spanish

Change of workers’ compensation carrier and medical provider network

California employers who used a California MPN with a prior carrier should give employees this document that lets them know about Sentry MPN.

View document

If you are a provider and interested in submitting medical bills electronically, please review the Clearinghouse and Payer ID in the sections below to ensure accurate routing of bills.

Workers’ Compensation Claims – All States

Medical and Dental Bills
Florists’ Mutual Insurance Company and Florists’ Insurance Company currently accepts electronic billing from medical providers on Workers’ Compensation claims. Medical providers will need to include Florists’ Mutual Insurance Company and Florists’ Insurance Company’s Workers’ Compensation Payer ID – J1417 and the patient’s Workers’ Compensation claim number with their submission.

Clearinghouse: Jopari
Suite 500, 1855 Gateway Boulevard
Concord, CA 94520 866-269-0554
eBill Enrollment: 866-269-0554
Customer Care: 800-630-3060
http://www.jopari.com/ebill-enrollment/

Workers’ Compensation Payer ID: J1417

For questions regarding Medical Bills or Reimbursements:
Medical and Dental Providers may contact 1-800-851-7740 Option # 1 for Claims then Option # 3 for validation of claim numbers.

Pharmacy Bills
Florists’ Mutual Insurance Company and Florists’ Insurance Company partners with Optum Pharmacy Benefits Management Program to process pharmacy invoices submitted electronically.
Contact: Optum
11000 Optum Circle
Eden Prairie, MN 55344
Phone: 1-877-470-9572
helpdesk3@optum.com
www.workcompauto.optum.com

Pharmacy Payer ID: Optum (PBM) BIN 004261 and Optum (PBM) PCN CAL

For questions regarding Pharmacy Bills or Reimbursements contact Optum:
Phone: 1-877-470-9572
Fax: 1- 888-579-0034
Email: helpdesk3@optum.com
Website: www.workcompauto.optum.com

Auto, Property & Casualty Claims – State of Minnesota, only

Medical, Dental, and Pharmacy Bills
Florists’ Mutual Insurance Company and Florists’ Insurance Company partners with Jopari to process medical, dental and pharmacy invoices submitted electronically. Florists’ Mutual Insurance Company and Florists’ Insurance Company’s Payer ID is C1033

Clearinghouse: Jopari
Suite 500, 1855 Gateway Boulevard
Concord, CA 94520
Phone: 866-269-0554
Website: www.jopari.com

Auto, Property & Casualty Payer ID: C1033

For questions regarding Medical Bills or Reimbursements:
Medical, Dental and Pharmacy providers may contact Florists’ Mutual Insurance
Company at 1-800-851-7740.

Minnesota Providers

Minnesota SB2193 requires Workers Compensation Carriers to provide the following information to Minnesota Workers Compensation Providers effective January 1, 2016.

Payer Information:
Claims Department
1800 North Point Drive
PO Box 8032
Stevens Point, WI 54481
1-800-851-7740
www.Hortica.com

Medical Bill Clearinghouse Information:
Medical and Dental Bills:
Florists’ Mutual Insurance Company and Florists’ Insurance Company partners with Jopari to process medical and dental invoices submitted electronically.

Payer ID:
Florists’ Mutual Insurance Company and Florists’ Insurance Company Payer ID with
Jopari is J1417. The Payer Identification number is populated in the 5010 ASCX12 837
TRs as follows:
Loop 2010BB Payer Name
NM108-PI (qualifier)
NM109=Payer ID number.
Reference Source: 5010 ASCX12 837 TR3 Implementation Guide available at http://www.wpc-edi.com/

Jopari’s Contact Information:
Address:
Jopari
Suite 500, 1855 Gateway Boulevard
Concord, CA 94520
Phone:
Customer Care – (800) 630-3060 option 2
Ebill Enrollment – (866) 269-0554
Email:
support@jopari.com
Website:
www.jopari.com

Claim Identification:
Medical and Dental Providers may contact Florists’ Mutual Insurance Company and Florists’ Insurance Company at 1-800-851-7740 Select option 1 – Claims and then select Option 3 – Existing Claim for validation of claim numbers.
Medical providers contracted with Jopari may utilize the Jopari Provider Portal @ www.jopari.com or contact Florists’ Mutual Insurance Company and Florists’ Insurance Company at 1-800-851-7740 Select option 1 – Claims and then select Option 3 – Existing Claim for validation of claim numbers.

Medical and Dental Invoice Submission:
Claim Identification number is reported in the 5010 ASC X12 837 TRs as follows:
Loop 2010 CA Patient Name
REF Segemnts=Property and Casualty Claim Number
REF01=Y4 (qualifier)
REF02+Claim Number
Reference Source: 5010 ASCX12 837 TR3 Implementation Guide available at http://www.wpc-edi.com/

Pharmacy Bills:
Florists’ Mutual Insurance Company and Florists’ Insurance Company partners with Optum Pharmacy Benefits Management Program to process pharmacy invoices submitted electronically.

Payer ID:
Florists’ Mutual Insurance Company and Florists’ Insurance Company Pharmacy Payer ID is Optum (PBM) BIN 004261 and Optum (PBM) PCN CAL.

Optum Contact Information:
Address:
Optum
11000 Optum Circle
Eden Prairie, MN 55344

Phone: 1-877-470-9572
Email: helpdesk3@optum.com
Website: www.workcompauto.optum.com

Claim Identification:
Pharmacy Providers may contact Florists’ Mutual Insurance Company and Florists’ Insurance Company at 1-800-851-7740. Select option 1—Claims and then select Option 3—Existing Claim for validation of claim numbers.

Beginning January 1, 2015, North Carolina requires Workers’ Compensation carriers to offer electronic payment to medical providers.

If you are a Workers’ Compensation Medical Provider and would like to receive payments via Electronic Funds Transfer (EFT) select an enrollment option after agreeing to the following terms:

Provider agrees to the following: This Authorization is between the Provider listed below (Provider) and Florists’ Mutual Insurance company, a member of the Sentry Group (“Florists’ Mutual Insurance company”) and governs Provider’s enrollment and use of the Electronic Funds Transfer (“EFT”) service. The contact person identified on the Authorization warrants and represents that he/she is authorized to act on behalf of the Provider and that his/her acceptance of the terms of this Authorization creates a legally enforceable obligation of the Provider. Provider authorizes Florists’ Mutual Insurance company to electronically transfer funds for all eligible and authorized claim payments to the bank account provided and understands that upon activation of the EFT service, Provider will no longer receive paper checks for claims payments. Provider warrants and represents that all information listed on this Authorization is accurate and agrees to immediately notify Florists’ Mutual Insurance company of any changes to the information or if it wishes to cancel enrollment. Florists’ Mutual Insurance company is not liable for any loss that Provider may incur as a result of the EFT service. Provider agrees to indemnify Florists’ Mutual Insurance company from and against all suits, claims, or losses arising from or alleged to arise from the Provider’s use of the EFT service. This Authorization constitutes the entire agreement between Florists’ Mutual Insurance company and Provider for the EFT service.

Please note:

• Please allow Florists’ Mutual Insurance company 7-14 days from receipt of all documentation to process EFT remittance, changes, or cancellation requests.

• Contact your financial institution to arrange for the delivery of the CORE-required Minimum CCD+ data elements needed for reassociation of the payment and the ERA.
  (The Corporate Credit or Debit is an ACH standard for EFT which is used to make/collect payments to/from other corporate entities. The CCD+ ACH Standard can include one record of payment-related information of up to 80 characters. Health Plans use the CCD+ to send payments via EFT, with a reassociation number that matches the EFT to its associated ERA (Electronic Remittance Advice))

• Mail your completed form to:
  Florists’ Mutual Insurance company
  PO Box 8032
  Stevens Point, WI 54481

Enrollment Options:

• Agree to the terms above and to enroll online

• Print an enrollment form

Enrollment Help Guide

If you have any questions, or wish to determine the status of your enrollment, please contact the EFT enrollment team at 855-477-6832 x 7153466385