LEHIGH UNIVERSITY’S WORKERS’ COMPENSATION PROGRAM
for Work-Related Injuries or Illness
____________________________________________________________________________
Workers’ Compensation Insurance is a statutory program that provides medical coverage and,
in some instances, income maintenance to employees who are disabled as a result of a work
related injury or illness. All full-time and part-time faculty, staff, and student employees
(salaried or on wages) are eligible for workers’ compensation coverage.
Insurance Benefits and Method of Payment
Payment for all medical services, supplies, and medicines that are reasonable and medically
necessary for rehabilitation, surgical, and hospital care (as determined by the workers’
compensation insurance company) is allowed at no cost to the employee. Also included are the
costs of orthopedic appliances and training in their use.
Employees who are disabled for more than seven (7) calendar days as a result of a work-related
injury or illness may also be eligible to collect disability income payments at a rate of
approximately 66-2/3% of their average weekly wage as defined by the Workers’ Compensation
Act. 1
Wage loss is not payable to an employee for the first seven (7) calendar days, unless the
disability exceeds fourteen (14) calendar days. This is known as the waiting period. After
fourteen (14) continuous calendar days of disability, the employee will retroactively receive
approximately 66-2/3% of his/her average weekly wage for the first seven calendar days of
disability.
During the first seven (7) days of disability, the employee may apply up to five (5) University
provided sick leave days. In the event the disability exceeds (14) calendar days, payment for the
first week of disability is made to the injured/ill employee as allowed under the Workers’
Compensation Act. The employee will be required to reimburse the University for those sick
days for which the employee was paid. The sick days will then be added back to the employee’s
sick time balance. Questions concerning the use of sick time as a result of a work-related injury
should be directed to the Office of Human Resources.
When an employee receives Workers’ Compensation disability payments at the rate of
approximately 66-2/3% of his/her average weekly wage, his/her university salary will be made
whole by accrued University short-term or long-term disability benefits that the employee has
available. The employee can also use accumulated sick time to supplement workers’
compensation income if neither short-term nor long-term disability income is available to
him/her. The amount of compensation paid by the Workers’ Compensation insurer to the injured
worker is reduced from the employee’s University gross payroll amount.)
Compensation rate is calculated using the injured employee’s wages earned in the four quarters preceding the date
of injury. Note: Although the rate is typically 66-2/3% of the employee’s average weekly wage, there is a
maximum compensation rate payable as defined by the Worker’s Compensation Act.
1
Prescriptions (Tmesys TM, Inc.) (see Exhibit C)
The University’s workers’ compensation insurer has signed an Agreement to participate in the
Tmesys TM Workers’ Compensation Pharmacy PPO. Employees should not use their group
prescription plan card for medicines that are compensable under their workers’ compensation
claim. Employees should take their prescription to one of the participating pharmacies and
provide the pharmacist with their social security number and date of injury. The pharmacist will
submit the bill directly to the insurer. In the event a pharmacist receives notice that Tmesys
cannot identify the injured employee or some other issue arises, the employee should pay for the
prescription and submit the receipt to the Risk Management Office.
Reporting a Claim

Workers’ compensation claims must be reported to the Risk Management Office
within one business day of the accident. (Phone: 610-758-3899; Fax: 610-758-5855)

Claim forms can be obtained by calling the Risk Management Office at 610-758-3899.
Required forms include the following, sample copies of which are appended to this
document:
- Notice to All Employees: Healthcare Provider Panel & Procedures
- Workers’ Compensation Employee Notification Acknowledgement Form
- Instructions for Completing the Employer’s Report of Occupational Injury or Disease
Form (LIBC-344-Rev 1-02)
- Employer’s Report of Occupational Injury or Disease (Form LIBC-344)
- PMA Injured Worker Prescription Information Sheet (Tmesys TM, Inc.)
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links

Working together, the injured employee and supervisor must complete the Employer’s
Report of Occupational Injury or Disease form, providing as much information as
possible regarding the injury. Completed forms must include the supervisor’s signature.

The completed Employer’s Report of Occupational Injury or Disease (Form LIBC-344)
and the signed Workers’ Compensation Employee Notification Acknowledgement Form
should be faxed to the Risk Management Office at 610-758-5855. The completed/
signed original forms should be sent via campus mail to the Risk Management
Office.
Employee Responsibilities



Immediately provide as much information as you can about your injury or illness to your
supervisor or departmental designee. This person will submit the requisite forms to the
Risk Management Office.
If you require medical treatment, follow the procedures set forth on the Notice to All
Employees – Healthcare Provider Panel and Procedures.
Sign and forward the Workers’ Compensation Employee Notification Acknowledgement
Form to the Risk Management Office.
Supervisor Responsibilities




Direct your injured employee to the Healthcare Provider Panel & Procedures Notice to
All Employees if they require medical treatment.
Forward the completed original Employer’s Report of Occupational Injury or Disease
(Form LIBC-344) and the signed Workers’ Compensation Employee NotificationAcknowledgement Form to the Risk Management Office within one business day of your
knowledge of the incident.
Immediately notify the Risk Management Office if an employee misses at least one day
of work because of the injury.
Notify the Risk Management Office when an employee returns to work after a workers’
compensation leave.
Note: Should the employee be disabled for an extended time period (e.g., post-surgery, etc.),
the supervisor and/or the employee should make every effort to keep the Risk Management
Office informed as to the injured employee’s progress. At a minimum, Risk Management
must be provided with a status update following each doctor’s appointment and be made
aware of the next scheduled appointment.
Instructions for Completing the Employer’s Report of Occupational Injury or Disease
Form (LIBC-344 Rev 1-02) (see Exhibit A.)

General Information:




Working together, the injured employee and his/her direct supervisor must complete
the injury report form.
Type or hand-write using blue or black ink. If typing, there is no need to put one
letter per box on the form. Stay within the range of boxes and avoid typing or
writing in the margins.
Employee’s address, phone number, etc., at the top of the form should be the
employee’s home information and not work information.
There is no need to complete any of the following codes: NCCI Class Code, SIC
Code, NAICS Code, Type of Injury Code, Part of Body Affected Code, or the Cause
of Injury Code.

Dates:
Enter all dates as MMDDCCYY. (for example: 01012002)

Phone Numbers:
Phone numbers must include area code. (for example: 4126241198)

Times:
Enter all times as HHMM, checking the AM or PM box, as appropriate. Do not use military
time. (for example: 0830 AM)

Date Returned to Work:
If employee has NOT lost any time, please enter the same date as the day of the injury.

Contact Name and Number:
This should be the name and campus number of the Lehigh University Workers’
Compensation administrator.

Type of Injury or Illness:
Briefly describe the nature of the injury or illness. (for example: contusion, fracture, sprain,
strain, etc.)

Parts of Body Affected:
Indicate the part(s) of the body affected by the injury or illness. (for example: neck, upper
or lower back, left or right wrist, etc.)

Cause of Injury:
Briefly indicate how the employee incurred the injury or illness. (for example: cut from
broken glass, fell from ladder, strain from lifting)

All Equipment, materials…. and How Injury/Illness Occurred:
Provide brief narrative of any equipment being used and/or how the injury occurred.

Initial Treatment:
Check applicable box(es)

Physician/Health Care Provider:
Include this information if treatment was provided before a completed injury report form was
submitted to the Risk Management Office.

Policy Number/Policy Period:
For Risk Management Use Only

Witness Name/Phone Number:
Provide this information if applicable

Person Completing This Form; Supervisor Signature:
Supervisor and/or Injured Employee’s name, title and phone number; Supervisor signs/dates
the form

SUBMIT THE COMPLETED FORM IMMEDIATELY TO THE RISK
MANAGEMENT OFFICE:
- Fax copy to Risk Management at 610-758-5855
- Send the original/signed form to the Risk Management Office via Campus Mail
Frequently Asked Questions
Your supervisor has been provided with the above Workers’ Compensation information and
should be able to clarify any questions you may have. However, should you have additional
questions concerning completion of the form, provider panel/procedures, etc., please contact the
Risk Management Office at 610-758-3899.
Am I required to treat with the PMA Insurance Group Panel of Physicians? If so, for how
long?
YES. The Pennsylvania Workers’ Compensation Act requires that employees of an
employer who has posted an approved healthcare provider panel treat with that panel for
work-related injuries for 90 days from the first day of treatment. If an employee chooses to
treat with a non-panel provider before the 90-day period has expired, the employer is not
responsible for paying the non-panel provider for services.
Who should I notify about my injury/illness?
Notify your Supervisor as soon as possible (claims filed later than 24 hours following an
injury may be denied or encounter other processing difficulties) so that the appropriate
Injury/Illness Report can be completed. This report (original) is sent to the Risk
Management Office which will file the claim with the University’s workers’ compensation
insurer.
If I’m taken to the hospital or am seen by another medical provider and they want information
about who they should send the bill to, what do I tell them?
The hospital/medical provider should forward invoices, along with the appropriate treatment
documentation as required under the Workers’ Compensation Act, to the attention of the
University’s workers’ compensation insurer: PMA Insurance Group; P.O. Box 25248;
Lehigh Valley, PA 18002-5248.
What should I do with the medical bill if I receive it at my home?
You can either mail it to the University’s workers’ compensation insurance company at the
above address or forward the bill to the Risk Management Office for processing.
What do I do if I receive medical bills or a collection notice as a result of treatment for my
work-related injury?
Lehigh University is responsible for medical bills deemed reasonable and necessary which
are directly associated with a work-related injury. All bills associated with the treatment of
a work-related injury should be forwarded to the University workers’ compensation insurer
– PMA Insurance Group, P.O. Box 25248, Lehigh Valley, PA 18002-5248. If you receive a
notice from a credit agency regarding unpaid bills which are associated with your workrelated injury, immediately contact the Risk Management Office at 610-758-3899.
What do I do if my physician has prescribed physical therapy during working hours?
Physical therapy should be scheduled before or after working hours. Time away from work
for physical therapy can only be authorized by your supervisor. Such time can be
compensated only if you use excused absence or vacation time available to you.
When will I get reimbursed for wage loss due to a work-related injury?
Workers’ Compensation only covers time lost due to a medically certified disability. This
means that a physician must restrict you from some activity that prevents you from doing
your job. You must have this medical documentation in order to qualify. Once a doctor has
certified your disability, there is a seven-day waiting period until workers’ compensation
benefits for wage loss begin. If you are entitled to any workers’ compensation payments,
the first check will be sent within 21 days from the first day of disability.
Who do I call if I have not yet received my check for Workers’ Compensation?
If your payment is late, contact the Risk Management Office at 610-758-3899
If I have missed work due to a work-related injury, what documentation is needed when I am
released to return to work?
A medical release (listing restrictions, if any) should be given to your supervisor and a copy
sent to the Risk Management Office.
Should you have additional questions, please contact the University’s Risk Management
Office at 610-758-3899. For questions concerning the recording of time off as a result of a
work-related injury and/or short-term or long-term disability benefits, please contact the
University’s Office of Human Resources at 610-758-3900.
Risk Management
rev: 8/4/04
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SAMPLE
To: Injured Employee
Re: Prescription Information Sheet – TMESYS Program
The pharmacies listed below participate in TMESYS – the workers’ compensation prescription program.
Should you need to purchase prescription drugs as a result of your work-related injury, provide the pharmacist
with your name, social security #, and date of injury. The pharmacist will process billing directly to TMESYS.
HOWEVER – should it be necessary for you to purchase a prescription before your claim has been processed
with the University’s workers’ compensation insurer, you should pay for the prescription and submit the receipt
to Risk Management for processing. DO NOT USE YOUR UNIVERSITY GROUP INSURANCE PLAN TO PAY
FOR A PRESCRIPTION NEEDED AS A RESULT OF YOUR WORK-RELATED INJURY. Subsequent
prescriptions/ refills required as a result of the work-related injury should be processed through the pharmacy
TMESYS plan.
If you have any questions, please contact Risk Management at x83899.
PMA Injured Worker Prescription Information Sheet TAKE TO PHARMACY
Injured Worker Name:_____________________________________Social Security #:_______________________________Date Of Injury:_______________
Dear Injured Worker,
On your first visit, please give this notice to any pharmacy listed on this insert to expedite the processing of your
approved Worker’s Compensation prescriptions, based on the established parameters by PMA.
Dear Pharmacist,
Please call Tmesys to obtain the ID # necessary to process the medications for this injured worker. Your company has signed an Agreement to participate
in the Tmesys Workers’ Compensation Pharmacy PPO. If you do not find us in your computer or your plan book, please call Tmesys immediately at 800-9642531. Thank you for your assistance.
Sincerely,
Tmesys, Inc.
ALL
PARTICIPATING
PHARMACIES
HAVE NOT BEEN
INCLUDED
ON THIS LIST.
PLEASE
CALL
CHAIN NAME
INDEX NAME
CHAIN NAME
INDEX NAME
CHAIN NAME
INDEX NAME
CHAIN NAME
INDEX NAME
A
&
P
index:
TYS
Happy
Harry's
index:TME
Pic
&
Save
plan
name:
T
or
TMESYS
Tri
Daly
Drugs
Carrier
code:
TMS
TMESYS REGARDING ANY QUESTIONS (800) 964-2531
Arbor Drug
Bartell Drug
Big B
Biggs
Bi-Lo Pharmacy
Bi-Mart
Brooks Drugs
Brookshire Brothers
Cardinal Health
Cub Pharmacy
CVS Drugs
Drug Emporium
Drug Fair
Duane Reade
Eckerds(FL)
Eckerds(all others)
Franck's Pharmacy
Fred Meyer
Fred's Pharmacy
Carrier code: TI
Index: TMS
index: TYS
Carrier code: TYS
input code: TMS
index: TMESYS
Code: TME
Condor Code: 2050
index: Call support
Carrier Code: TYS
Condor Code: 8822
TYS
index: TMESYS
TMESYS
Termimal plan:2802(FL)
Termimal plan:2801
price code: TM
TYS
TMESYS
Harco Phcy
Hi-School Pharmacy
HEB Phcy
Hooks, Brooks& Super X(HIS)
Horizon Pharmacy
HyVee Drugtown
J & J Pharmacy
Joel & Jerry's
K&B
Kash N Karry
Kerr Drugs
K-mart phcy
Kroger Phcy
Laverdiere's
Lifecheck Drug
Long's Phcy
Medicine Shoppe
Medistat Phcy
Milner-Rushing Drugs
index: TYS
TMESYS Central Billing code:TM01
price code:T9
index: TME
TYS
index:bin # in 3rd party set up
TCS
index: TME
Plan code:TMESYS
plan: TYS
TMESYS
Carrier code: TYS
index: TS,TM,YS
plan name: TMESYS
TMESYS
plan: #1,TMES
varies by each store system
Condor code: 2425
compensation as Tom Ashley
Prevo Drugs
Publix
Raley's/Bel Air Phcy
Randalls Pharmacy
Revco drugs
Rite-Aid drugs
RX Discount Pharmacy
Sack-n-Save
Safeway Phcy
Sav-A-Lot
Sams Club Pharmacy
Save Mart
Shopko Pharmacy
Shop N Save
Shop-Rite
Stop N Shop
Super D
Super Valu
Super X (HSI)
input code: TS
carrier:TME plan: SYS or TYS
plan: Tmesys
TMSRX
TMWC
TMESYS
input code:TME
plan#: 6012 or 5097
processor code: TME or TYS
60
carrier code: TME
Carrier code: TYS
TYS
carrier code: TYS
TYS
146
Plan name:332
carrier code: TYS
index: TME
Turner Drugs
Twin Value
U-Save
United
Vons
VIX Pharmcay
Walgreens
Wal-Mart phcy
Wegman Pharmacy
Weis Markets
Winn-Dixie
Index: Tmesys
carrier code:TYS
index: TME
TYS
carrier: TME
carrier code: TME
carrier code: TMEWC
carrier: TME
carrier code: TME
carrier code: TYS
index: TME (plan 2066)
*ALL PARTICIPATING PHARMACIES HAVE
NOT BEEN INCLUDED ON THIS LIST.
PLEASE HAVE YOUR PHARMACY CALL
TMESYS REGARDING ANY
QUESTIONS/AUTHORIZATIONS
(800) 964-2531.