Third-Party Claims Administration Services

The Vendor is required to provide for third-party claims administration services for on the-job injury claims involving state public education employees.
- Injury Reporting Requirements: Employees must sign the injury reporting form. Employers declining to submit a report after timely notice must issue written findings supporting that decision.
- Dispute Resolution: Disputes are referred to the Public Education Employee Injury Compensation Program Review Board, with hearings conducted by appointed hearing officers upon request.
- Covered Employees:
•    Full-time Public Education Employees
•    Adult bus drivers
- Estimated Annual Claim Volume:
•    Medical-Only Claims: 216
•    Lost-Time Claims:
- Workers’ Compensation
•    Claim intake, investigation, and compensability determinations
•    Statutory benefit administration under Alabama law
•    Medical management and utilization review
•    Indemnity calculation and payment
•    Return-to-work coordination
•    Litigation and defense counsel management
•    Reserve setting and periodic reserve adequacy reviews
•    Subrogation identification and recovery
•    Vendor management (medical, bill review, nurse case management, pharmacy)
•    Regulatory reporting and required filings
•    Coordination of benefits with the Public Education Employee Health Insurance Program (PEEHIP)
- Claims Handling Philosophy – Education Sector
•    Early investigation and educator contact
•    Coordination with school systems and administrators
•    Reserve philosophy and governance
•    Litigation avoidance strategies
•    Return-to-work approaches appropriate for school environments
•    Performance measurement and continuous improvement
- Medical & Cost Containment Services
•    Medical bill review processes
•    Nurse case management (telephonic and field)
•    Pharmacy benefit management
•    Utilization review and treatment guidelines
•    Provider network strategies and reimbursement rate negotiations
•    Outcome measurement and reporting