Old Republic Contractors Insurance Group (ORCIG) is pleased to offer the Gallagher Bassett Platinum-M MPN. This MPN is a custom carve-out network developed specifically for ORCIG.

As a custom MPN offering, the Gallagher Bassett Platinum-M MPN provides ORCIG with increased flexibility to choose their providers to participate in the Gallagher Bassett Platinum-M MPN.

Gallagher Bassett Platinum-M MPN Implementation Steps

The approved MPN is called the Gallagher Bassett Platinum-M MPN, under DWC Identification Number 2471.

 

Step 1:  Post the DWC-7 at the workplace.

The DWC-7 must be posted and kept posted in a conspicuous location frequented by employees, during the work hours of the workday.

Please click on this text to download the DWC-7

 

Gallagher Bassett Services (GB), must be named as the claims administrator, along with the GB branch phone number. Old Republic General Insurance Corporation must be listed as the workers' compensation insurer and policy expiration date must also be listed.

Gallagher Bassett Services, Inc. Claims Branches

•            P.O. Box 610, Roseville, CA 95661 Telephone Number: 1-866-456-8402 GB Branch # 180

•            P.O. Box 4200, Rancho Cucamonga, CA 91729, Telephone Number: 1-866-517-6782 GB Branch # 164

The revised DWC-7 notice includes changes to its wording and introduces three new data fields:

  • MPN Identification Number
  • MPN Medical Access Assistant Telephone Number
  • MPN Contact Person Telephone Number

Here is the DWC-7 information for the Gallagher Bassett Platinum-M MPN

  • MPN website:  www.talispoint.com/cvty/gbmpn
  • MPN Effective Date:  Differs by client and client location
  • MPN Identification number:  2471
  • Medical Access Assistant Phone Number:  1-855-446-9021
  • MPN Contact Phone Number:   1-855-203-2845

 

Step 2.  At time of injury, the injured worker must receive a copy of the MPN Employee Notification Document.

Click here for the MPN Employee Notification Document - English

Click here for the MPN Employee Notification Document - Spanish

MPN Employee Acknowledgement Letters

The MPN regulations are silent about Employee Acknowledgement Letters. As an employer, you have the right to use acknowledgement letters for your employees to sign when you implement your MPN.

Here are some sample acknowledgement forms for your use.

For a MPN English Acknowledgement Form, please click on this text.

For a MPN Spanish Acknowledgement Form, please click on this text.

 

Step 3. Create an MPN Panel Card and post it at the workplace. Click on the text below to look up providers and to create a medical panel card for your work site.  

You may also look up providers on this same Internet Site.

www.talispoint.com/cvty/gbmpn

 

Step 4.  Your MPN will be effective when your employees are notified.

If you have any questions with regard to implementation, please contact ORCIG Claims Administrative Assistant, Marco Ponce,

at 626-683-5160 or mponce@orcig.com.

It is very important to confirm with Marco Ponce the date you have completed MPN enrollment.