General Information

Mayo Clinic employees may be eligible and qualify for job protection under the Federal Family and Medical Leave Act (FMLA) and wage replacement under either Workers' Compensation benefits (work-related injury/illness) or the Short Term Disability (STD) benefit (non-work related injury/illness). Further information on FMLA eligibility and qualifying medical conditions is available under Leave of Absence under the More tab. If the employee is not eligible or the leave does not quality for job protection under FMLA, they may be eligible for a personal leave for a serious health condition or disability. Review the information below to begin the process of submitting a leave and applying for benefits.

Rochester Employees WITH access to the Mayo Clinic Intranet: Please review the Work Connect Program Intranet site for complete process information for a work-related or a non-work related injury/illness.

Rochester Employees WITHOUT access to the Mayo Clinic Intranet: Please review the following information to understand the processes to follow when you experience a work-related or a non-work related injury/illness.

WORK RELATED INJURY/ILLNESS

Illnesses or injuries are considered work related if they arise out of or in the course and scope of your employment. Workers' Compensation state statutes and rules outline the process used to provide wage replacement and medical and rehabilitation benefits to employees who suffer a work-related illness/injury.

If you become ill or are injured because of your job, you may be entitled to Workers' Compensation benefits. Work Connect Program staff from Recovery and Claims Services (RCS) are here to assist you following submission of an Employee Incident Report or requesting a leave and will work with you throughout the recovery process to allow you to stay at or return to work as quickly and safely as possible.

The steps below should be followed to assist Mayo Clinic Rochester employees with reporting a work-related injury/illness, submitting a corresponding FMLA leave if missing work, seeking treatment and payment for medical care related to an approved work-related claim, and participating in return to work activities.

STEP 1: Report Incident

1. Notify your supervisor immediately about the situation that you feel is a work-related illness injury/illness.

• • Report a blood and/or body fluid exposure immediately to your local Employee/Occupational Health Services staff.

1. Complete and submit an Employee Incident Report through RCS Online Services.

• • Current employees can access the Employee Incident Report through RCS Online Services.  Please review the RCS Online Services Quick Reference Guide for access information.
    • If you are unable to complete the Employee Incident Report, contact your supervisor and request that they complete the report on your behalf.
  • Once the Employee Incident Report has been submitted, RCS Claims staff will be assigned to review the Workers' Compensation claim for approval/denial and, if approved, will ensure payment of all reasonable and necessary medical services and process lost wages on any missed work following the appropriate waiting period.
  • If you are missing time from work, RCS Claims will review to determine if you are eligible and qualify for FMLA job protection.  There is no need to submit a separate leave request.
    • Benefits may be delayed/denied if the Employee Incident Report is not submitted in a timely manner.

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STEP 2: Seek Treatment

1. Seek medical treatment as necessary.

• • Your choice of a treating provider for your work-related illness or injury is governed by state Workers' Compensation statutes and rules.
  • Review the information regarding seeking treatment noted in the email received following submission of the Employee Incident Report.
  • Prior authorization may be required from Recovery & Claims Services Claims Section.
  • Providers treating an employee for a Workers' Compensation injury must provide treatment pursuant to state statutes.
    • Treatment falling outside of the state treatment parameters can be received, as long as the provider requests pre-approval from the RCS Claims Adjuster prior to the treatment.
    • Your provider and/or care team should contact the RCS Claims Adjuster at 507-422-0505 to obtain approval for treatment falling outside of the treatment parameters.
  • If inpatient surgery is planned for the approved Workers' Compensation work-related injury or illness, inform your surgeon that prior authorization is needed and request that they contact your assigned RCS Claims staff with information on diagnosis and medical documentation indicating the actual cause of the injury or illness.
  • Contact your RCS Claims staff to discuss any potential required authorizations.

1. Inform any non-Mayo treating provider that the treatment is related to a work injury or illness and request itemized medical bills be sent to:

• • MAYO
    PO Box 6575
    Scranton, PA 18505-6575
    Email:  Mayo@divintech.com (preferred)
    Fax:  1-855-204-9215
    Jopari eBill: eBill # 41193
    • If you receive a bill for treatment at Mayo Clinic or a co-pay (billed to Mayo Clinic insurance) for medical treatment for a work-related injury or illness, contact Patient Account Services at 507-266-5670 or 1-800-660-4582 to let them know that the bill should be sent to Mayo Clinic Recovery and Claims Services.
    • If you receive a bill for treatment from a non-Mayo Clinic provider, contact the provider and request that the bills be sent to the address above.
    • Employees not utilizing a Mayo Clinic Pharmacy for prescriptions or durable medical equipment (DME) should pay for the item out of pocket and submit the purchase receipt for reimbursement to Recovery and Claims Services, Pavilion 4 (fax 507-255-7198).  Do not provide the external pharmacy with your Mayo Clinic benefit information.
    • Keep track of mileage outside of commuting for medical appointments that are related to the Workers' Compensation claim on the Workers' Compensation Expense Reimbursement Log, MC2338-83, as noted in correspondence from the assigned RCS Claims staff.

1. Attend all scheduled medical appointments and follow the recommended treatment plan.

STEP 3: Submit Work Restriction Documents

1. Request your treating provider complete the Medical Status Report for Mayo Clinic Employees (MC2338-02) (preferred method) if you are unable to work or require work restrictions (including reduced FTE).

• • Other documentation is acceptable as long as the documentation contains:
    • 2 employee identifiers such as employee name, date of birth, and Employee ID (a Medical Record Number or MRN is not an employee identifier);
    • start and end dates employee is unable to work, able to work reduced FTE, and/or able to work with specific restrictions;
    • information on specific medically-based work restrictions;
    • legible provider signature OR illegible provider signature with a printed provider name.

1. Submit work restriction documentation to the Work Connect Program via:

• • • email to workconnectrestrictions@mayo.edu;
    • fax to Work Connect Program at 507-255-7198;
    • drop off paper copy to SMH Domitilla MN 101, Rosa Parks Pavilion 4th Floor, or Eisenberg SL-49.
  • Work Connect Program staff will generate a Work Status Report (WSR) to you at any personal email addresses provided as well as your Mayo email address, your supervisor, and other RCS Claims and Return to Work Section staff that are assigned to your case.
  • A WSR will NOT be generated if the absence is less than 3 days or there are no current restrictions when the work restrictions were sent to the Work Connect Program staff.

STEP 5: Work with Staff to Stay At/Return to Work

1. Communicate with your supervisor and discuss any restrictions.

• • Develop a return to work plan with your supervisor and assigned Return to Work Coordinator.

STEP 6: Assist with Investigation if Requested

1. Cooperate with Mayo Clinic Safety and other parties that are reviewing the work-related injury/illness.

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NON-WORK RELATED INJURY/ILLNESS

The steps below should be followed to assist Mayo Clinic Rochester employees with reporting a non-work related injury/illness, submitting an FMLA leave request if missing work which includes applying for short-term disability (STD) benefits, and participating in return to work activities.

STEP 1: Submit Leave

1. Discuss the need for time off with your supervisor.

• • If you are having surgery due to a serious health condition, please provide your supervisor 30-days’ notice or as soon as possible if surgery is prior to that.  Your supervisor can request that specific timeframes be avoided for staffing purposes.
  • It is not necessary to provide medical details to your supervisor unless you choose to do so.

1. Access Incident Reporting and Leave Online Services available from Mayo Clinic's Employee Online Services site by clicking here or typing "https://mayoemployees.org" in the web browser address bar and select on the appropriate leave request (for birth/placement of child, your own medical condition, a family member's medical condition, or related to your or a family member's military activities).

• • If you are submitting a leave for your own medical condition, you will be presented with the Employer Request for Disclosure of Protected Health Information form.  Please complete, date and electronically sign this form and submit.  If the form is not submitted or is invalid, the Claims staff will be unable to review your leave for any STD benefit.
    • Submitting the authorization form may avoids delays in receiving benefits.
  • After the leave has been submitted, RCS Claims staff will review your leave request and any potential associated benefit and you will be contacted regarding the outcome of the review or for a request for additional information.
  • If a leave has been submitted and changes are needed, return to the Incident Reporting and Leave Online Services site and select Update Existing Leave from the left navigation or the tile.  Select the appropriate active leave and enter the updated information.  The update will be reviewed by RCS Claims staff and determined if the update can be approved.
  • If you are unable to access Incident Reporting and Leave Online Services, contact your supervisor and request that they submit a leave request on your behalf.
    • If your supervisor submitted the leave on your behalf, RCS will send you a packet of information in the mail to your home address, including the Employer Request for Disclosure of Protected Health Information form (authorization) so that your leave can be reviewed for any available benefits.

STEP 2: Respond to Requests for Information from RCS Claims Staff

1. Respond to correspondence from RCS Claims staff if additional information is needed to review the leave.
2. Watch for correspondence regarding whether the leave was approved or denied.

• • If the leave is denied, discuss other leave options with your supervisor.
  • If denied because you do not have the qualifying hours (number of work hours needed to qualify for FMLA), once you reach the qualifying hours worked you can reapply for FMLA.
  • Your qualifying hours can be obtained by contacting or RCS Claims (507-422-0505).

STEP 3: Submit Work Restriction Documents

1. Request your treating provider complete the Medical Status Report for Mayo Clinic Employees (MC2338-02) if you are unable to work or require work restrictions (including reduced FTE).

• • Other documentation is acceptable as long as the documentation contains:
    • 2 employee identifiers (employee name, date of birth, and/or Employee ID);
      • a Medical Record Number or MRN is not an employee identifier.
    • start and end dates employee is unable to work, able to work reduced FTE, and/or able to work with specific restrictions;
    • information on specific medically-based work restrictions;
    • legible provider signature OR illegible provider signature with a printed provider name.

1. Submit work restriction documentation to the Work Connect Program via:

• • email to workconnectrestrictions@mayo.edu;
  • fax to Work Connect Program at 507-255-7198;
  • drop off a paper copy to SMH Domitilla MN 101, Rosa Parks Pavilion 4th Floor, or Eisenberg SL-49.

1. Work Connect Program staff will generate a Work Status Report (WSR) to you at any personal email addresses provided as well as your Mayo email address, your supervisor, and other RCS Claims and Return to Work Section staff that are assigned to your case.

• • A WSR will NOT be generated if the absence is less than 3 days or there are no current/active restrictions when the work restrictions were sent to the Work Connect Program staff.

STEP 4: Work with Staff to Stay At/Return to Work

1. Communicate with your supervisor and discuss any restrictions.

• • Develop a return to work plan with your supervisor and assigned Return to Work Disability Compliance Advisor.

STEP 5: Remain in Contact with RCS Claims Staff

1. Keep in contact with your Claims representative, particularly if:
   • you have changes to your restrictions (including being able to return to work with or without restrictions).
   • are not progressing as planned and need an extension beyond the approved leave date range.

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