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Information needed to file a claim
The provider must obtain certain information when reporting a new injury

The provider must obtain certain information when reporting a new injury, such as:

Injured worker information

  • Name
  • Address
  • Telephone number
  • Date of birth
  • Social Security number
  • Gender
  • Marital status
  • Occupation

 

Injury information

  • Type of accident (accident, occupational disease or death)
  • Date of injury
  • Will injury likely result in more than seven days off work?
  • Accident description
  • Date of initial treatment
  • Date last worked and date returned to work (estimate return-to-work date if exact date is unknown)
  • International Classification of Diseases (ICD) diagnosis codes (specific diagnosis description, including primary ICD)
  • ICD location (right, left, bilateral)
  • ICD site (digits or teeth)
  • Injury description (body part injured, i.e., first joint of left index finger)
  • Is diagnosis causally related to this industrial accident?

 

Employer information (Where is this injured worker employed?)

  • Employer name
  • Employer address
  • Employer telephone

 

Provider information

  • Initial treating provider name and BWC provider number (may be a hospital or physician)
  • 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 First Report of Injury (FROI) providers are required to submit medical documentation.