Nebraska State-Specific Information

Forms

These are the required forms to use when reporting and managing workers' compensation claims in Nebraska. If you have specific questions about any of these forms or resources, contact your SFM claims representative.

• First Report of Injury
  Report injuries online. It's the fastest, easiest way to report. Or use the Nebraska First Report of Injury form to report injuries to SFM.
• Choosing a doctor for a work-related injury information sheet
  The right to choose and change doctors is governed by Nebraska statutes and rules. This information sheet gives a simplified explanation of those rights. Give this sheet to injured employees when they are considering changing doctors.
• Employee's choice or change of doctor form
  You are required by Nebraska state law to have your injured employees complete this form at the time of injury. Send the completed form to SFM along with the First Report of Injury. It is also available in Spanish.
• Temporary prescription information sheet and cards
  This prescription card allows employees to fill their initial work-related injury prescription without any out-of-pocket expense. Give it to your employee when he or she becomes injured and plans to see a doctor. A longer-term prescription card is mailed to the employee once SFM has received the First Report of Injury.

Web links

• Nebraska Department of Insurance
• Nebraska Safety Council
• Nebraska Workers' Compensation Court

An employee in Nebraska who has sustained a work-related injury has the right to choose his treating physician only when there is a documented treatment history between the employee or an immediate family member and the specified physician. If the employee does not have or does not choose such a physician, then you, the employer, may select the physician except in special circumstances where major surgery is to be performed or if the injury involves dismemberment.

Additionally, Nebraska employers must notify an injured employee of his right to choose a treating physician at the time of injury. If you fail to do this, the employee can seek medical treatment with any physician. Use the Nebraska "Employee choice or change of doctor" form to satisfy the statutory employee notice requirements. Have the employee sign and date the form and send a copy to SFM.

In emergency medical treatment situations, the rules regarding choice and change of doctors don't apply until after the emergency is resolved.

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After an injury occurs and you're ready to submit the First Report of Injury, make your job easier by pulling together the necessary information. Most of it may be in the employee's personnel file.

Items needed:

• Employee's Social Security number
• Employee's full name
• Employee's date of birth
• Employee's current address
• Your SFM policy number and coverage effective and expiration dates
• Accurate wage information to reimburse the employee for lost wages
• Date the employer was notified or became aware of the injury
• Date the disability began, and the date of the last day the employee worked
• Date employee returned to work
• Did you pay the employee for lost time on the day of injury?
• Treating physician's name and address along with the hospital or clinic name, if the employee sought treatment

Details about the accident:

• How did the injury occur?
• What was the employee doing before the incident?
• What was the injury or illness? Include specific parts of the body.
• What tools, equipment, machines, objects or substances were involved?

If you need assistance completing a First Report of Injury, call the SFM claim reporting hotline at (800) WC-CLAIM [922-5246].

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When a claim is reported to SFM, the injured employee receives the following:

• Acknowledgement letter from your SFM claims representative
• Personalized "Prescription services identification card" to be used to fill work-injury related prescriptions
• Brochure on workers' comp benefits and answers to common questions
• Mileage and travel reimbursement form

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State laws allow employers to have access to injured employees' medical records so they can see work restrictions ordered by physicians, which are usually documented on a Report of Work Ability form.

It's good to clarify work restrictions and transitional job tasks with the physician, but remember to document everything and keep the employee informed.

Other rules for handling confidential medical records:

• By law, you cannot combine medical records with the employee's personnel file. Keep a separate medical file.
• Never give medical information to a third party without the employee's written consent.
• Don't use medical information as grounds to fire or discriminate against an employee. Doing so violates several federal and state laws.

HIPAA's effect on workers' compensation

For the most part, Health Insurance Portability and Accountability Act (HIPAA) privacy rules do not apply to workers' compensation claims. Some provisions apply, but only to the workers' compensation insurance company or the self-insured employer, not the general employer.

The general guideline for employers on handling workers' compensation is that you have a right to discuss an injured employee's progress and existing medical history with the physician, as it relates to the injury.

Medical providers may be unclear about the HIPAA law as it applies to work comp and may be reluctant to give you information. If you're having trouble getting information from a provider, call your SFM claims representative at (800) 937-1181.

For more information on HIPAA and how it relates to workers' compensation, visit the federal Office of Civil Rights (OCR), which administers the HIPAA privacy Rule. Its website has helpful "Frequently asked questions" and "Disclosures for workers' compensation purposes."

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Insurance fraud may come in many different forms, including an injured employee who intentionally misrepresents information or hides the truth with the intent to receive money or other benefits from an insurance company.

Even if you suspect fraud, you must still report the injury to SFM. Your SFM claims representative will investigate the claim and determine whether the evidence falls under the state's legal definition of fraud.

If you suspect a claim is fraudulent, contact your SFM claims representative or SFM's Special Investigations Unit at 800-937-1181, ext. 4288.

For more information on insurance fraud in Nebraska, contact the Nebraska Department of Insurance, Insurance Fraud Prevention Department at (402) 471-2201.

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If the injured employee is missing time from work—either directly following the injury or any time during the course of recuperating from the injury—it is essential that you notify your SFM claims representative. Unless you tell SFM that an injured employee is missing work, the employee won't receive the workers' compensation wage-replacement benefits he or she is entitled to by law. That may trigger state penalties or prompt the employee to contact an attorney.

If the employee is losing time from work directly following the injury, be sure to fill in the "Last work date" box on the Nebraska First Report of Injury form.

If the employee loses time from work after you've already submitted the First Report to SFM, call your claims representative immediately at (800) 937-1181 to let him or her know when the employee first began losing time from work. Your organization may be assessed a state penalty if you do not notify your SFM claims representative immediately after you have knowledge that the employee will miss time from work due to the injury.

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State law requires a specific number of days to pass before an injured employee is eligible to receive workers' compensation wage-loss benefits. Additionally, most states require a specific number of days that the employee is off work before wage-loss benefits are retroactively paid from the beginning of the waiting period. The number of days in the so-called "waiting period" and the retroactive period varies by state. Each state also specifies which days count and what constitutes a day.

Employees who have been injured at work in Nebraska must wait seven days following an injury where they're losing time from work to be eligible to receive wage-loss benefits. Once an injured employee has passed six weeks off work because of the injury, he or she is entitled to be retroactively paid wage-loss benefits starting from the first day of the waiting period.

If the employee is injured at work and misses, say, 10 days of work, SFM would pay the employee wage-loss benefits for the 8th through the 10th days off work due to the injury. SFM would not pay wage-loss benefits for the waiting period since the employee did not hit the retroactive period.

A "day" is defined by Nebraska workers' compensation statute to be the first full or partial calendar day an employee misses work because of the injury.

For more information about the Nebraska waiting period, please contact your SFM claims representative at (800) 937-1181 or visit the Nebraska Workers' Compensation Court website.

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