- Contact a preferred urgent care facility by telephone prior to sending the injured worker.
- Inform the urgent care that you have an injured worker coming and that Benchmark Administrators is the claims administrator.
- If a worker is seriously injured and needs immediate care or is transported by ambulance, the employer should have a co-worker or supervisor go with the injured worker to assist the injured worker with any insurance related information that the medical provider may require.
- If possible, the injured worker must return to your office or job site after seeing the doctor and give you the doctor’s signed return to work slip or disability slip.
- It is necessary that the employer complete the required ICA Online Form 101 and notify us immediately once the form is approved by the Industrial Commission and emailed back to the employer. Please forward the returned First Report of Injury – ICA 101, along with the return to work/disability slip from the doctor to Benchmark Administrators as soon as possible. It can be sent by email to coverage@trean.com or faxed to 833-377-2098.
Arizona
When an employee is injured on the job, proceed with the following:
Required State Reporting Forms and Procedures
- Arizona ICA Employers’ Report of Injury Online Form
(First Reports of Injury must be filed online. Paper submissions are no longer accepted in Arizona.) - Arizona ICA Community Website
Additional Forms
Please Send the Form ICA 04-0101, Medical Slip and Prescription Bills to:
P.O. Box 46350
Las Vegas, NV 89114
Telephone: (208) 848-2020
Toll free (800) 362- 5198
Fax (208) 853-4076
Medical Billing
Medical bills should be mailed to:
P.O. Box 14365
Lexington, KY 40512
Process medical bills electronically through the following ebilling options:
Western Integrated Care (WIC), on behalf of BMA payer ID is LV191 via ebilling provider Data Dimensions or J4466 or J4005 via ebilling provider JOPARI.
If providers are interested in enrollment or have questions about submitting via Data Dimensions or Jopari Solutions, please reach out to the following support resources:
Data Dimensions: www.datadimensions.com/support
Jopari Solutions: www.jopari.com/ebill-enrollment or www.jopari.com/contact-us
24-HOUR CLAIM REPORTING HOTLINE: 1-800-362-5198
Customer Service Representatives are on call 24 hours per day to assist you. Please have the injured worker's information available as well as the accident description.