CLAIMS

Reimbursement Procedure


 

Medical and Legal Bills:

  • Prior to making payment, send in all bills to Sedgwick CMS to be audited.  The audit helps to ensure that the charges for services provided are correct and reasonable.  In addition, it prevents you from being double billed by a provider.

  • When the audit sheet is returned from Sedgwick, make the check payable for the amount stated on the audit.  Also, return the audit sheet with your payment, as the provider will not know what charges you are paying without it.

  • Send a copy of your payment to Sedgwick CMS along with the payment recommendation cover sheet.

  • You will be reimbursed by OOSI for all payments after your per claim deductible is satisfied.

Wage Replacement:

  • In the event of an indemnity situation (lost wages), it is important to remember to reimburse the employee at the Plan rate, which is 85% of the employee’s wage beginning on the first full day of missed work up to a maximum weekly amount of $1,000 for a maximum period of 52 weeksWhen submitting lost wages for reimbursement, send copies of your checks with specific details of payment.  For example:  if the injured employee missed 5 days of work out of a 2 week pay period, specify the amount reimbursed just for lost wages.  Do not send in a copy of the pay stub without detailing what was paid.

New!  Prescriptions:

  • Effective 12/1/15, no out-of-pocket cost to the owner operator or employee for prescriptions, therefore, no reimbursement process for the owner operator.  Prescription medications for employee injuries are billed directly to the pharmacy benefit manager and are paid directly by the program and will no longer be included as part of your claim expense.

Sedgwick CMS:
Contact person: Chuck Eastwood – Direct 210-332-1611
9601 McAllister Freeway, Suite 500
San Antonio, TX 78216
Phone: 210-332-1500  or 1-800-800-3795
Fax: 210-332-1590