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Data elements required when contacting the managed care organization (MCO)
When contacting the MCO to report a new injury, the provider must obtain specific injured worker, injury, employer and provider information.
Note: The asterisk * indicates data elements required to report an injury within the 24-hour time frame.
You must provide the remaining data elements, if not available at the time of the first report, to the MCO no later than five calendar days from the initial treatment.
Injured worker information
- *Name
- *Address
- *Telephone number
- *Date of birth
- *Social Security number
- *Gender
- *Marital status
- *Occupation
Injury information
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*Type of accident (accident, occupational disease or death)
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*Date of injury (date of death, if applicable)
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*Will injury likely result in more than seven days off work? (yes or no)
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*Accident description (detailed account of how accident happened)
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Date of initial treatment
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Date last worked and date returned to work (estimate return-to-work date if exact date is unknown)
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International Classification of Diseases (ICD-9) diagnosis codes (specific diagnosis description, including primary ICD-9)
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ICD-9 location (right, left, bilateral)
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ICD-9 site (digits or teeth)
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*Injury description (body part injured, i.e., first joint of left index finger)
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*Is diagnosis causally related to this industrial accident? (yes or no)
Employer information (Where is this injured worker employed?)
- *Employer name
- *Employer address
- *Employer telephone
Provider information
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*Initial treating provider name and BWC provider number (may be a hospital or physician)
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Name of physician of record and BWC provider number (If the provider sends his or her BWC provider number to the MCO, BWC will send the provider, who reported the injury or the provider of record, a letter with the status of the claim and the allowed conditions.)
In addition to submitting the FROI, providers are required to submit medical documentation within specific days.
Click here to view the provider Tasks and Time Lines chart.
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