The City provides, at no cost to you, Workers’ Compensation coverage for health care services for on-the-job injuries and occupational diseases. This coverage is provided through a managed care arrangement as outlined in Section 440.134 of the Florida Statutes.
Under the Workers’ Compensation law, it is mandatory that any on-the-job injury or accident be immediately reported to your supervisor so that the proper documentation can be filed. A report is filed with the State of Florida to ensure that any benefits the injured may be entitled to are not jeopardized by failure to report. Failure to file within seven days may result in a fine to the city and a loss of benefits to you.
If the injury is severe and immediate attention is required, you are to go directly to Mt. Sinai Aventura Emergency Room. You (or whoever may go with you) must inform the Emergency Room that you have incurred a work-related injury and you are not to use your city insurance ID card for payment or filing claims. Confirmation of or authorization to file Workers’ Compensation claims may be directed to the City’s Human Resources Department (305) 792-1708 or Yael Londono at (786) 271-4389.
If the injury is not severe, you must visit only health care providers in the managed care network. If you receive treatment outside the managed care network without prior authorization from the insurance carrier, such treatment is not covered by the employer or the insurance carrier. For a list of authorized providers, contact Preferred Governmental Claims Solutions (PGCS) at 1-800-237-6617.
If your Workers’ Compensation primary care physician needs to refer you to a specialist, you will be referred to a physician within the Workers’ Compensation managed care network (from the list). You are permitted to make one change to another primary care physician within the Workers’ Compensation network and one change to another provider in the same specialty within the Workers’ Compensation network during treatment for your work-related injury. You may also request a second medical opinion. You should contact your case manager or adjuster about provider changes. Any additional change request must go through the managed care grievance procedure.
The city may provide full salary to employees injured on the job for a period of up to 13 weeks, (in lieu of the 2/3 salary offered by the state). Therefore, you must turn in any Workers Comp checks received to Human Resources. You must provide a physician’s report after each doctor’s appointment, which includes “Time-in” and “Time-out”, to your supervisor who will forward the information to Human Resources. A worker’s comp claims adjustor and/or nurse will contact you within a short period of time to coordinate the follow-up care, if needed, and workers comp benefits.
The Third Party Administrator for the City of Sunny Isles Beach is:
Initial Pharmacy Instructions:
Matrix Pharmacy program is utilized to allow employees to fill their initial prescriptions without untimely waits for authorization. The employee needs to give the pharmacy the Matrix phone number, which is 877-804-4900. The pharmacy should call Matrix and a three-day supply of medication will be dispensed. Matrix cards will be sent to each employee with the initial Workers’ Compensation package for continued use. The adjusters/nurses can update dispensing information as needed so the employee can get their prescription filled with ease.