Business and Administration

EMPLOYEES COVERED

All Auburn University and Auburn University Montgomery employees are eligible for benefits provided by the OJI Program. This includes:

• full-time and part-time employees
• temporary workers (TES employees)
• student employees (injury must occur in the course and scope of duties as an Auburn University employee)

The OJI Program does not provide benefits to volunteers, independent contractors, or workers employed outside of the University.

All OJI claims are investigated for compensability by the university’s Third Party Administrator (TPA). Benefit eligibility is based on employment status, and whether the injury, illness, and/or disability results from an incident arising “out of and in the course of an employee’s scope of employment” with Auburn University.

INCIDENT AND CLAIM REPORTING AND REIMBURSEMENT

Claims should be reported through Auburn University’s Claims Portal

Prior authorization for “initial” treatment is not required, though AU Main campus employees should seek initial medical treatment through the AU Medical Clinic, or the AUM Student Health Center (for AUM employees).

Employees located off-campus should seek care from a Blue Cross Blue Shield PPO physician. Emergency care should always be directed to the nearest emergency room. Referrals to specialists should be made in consultation with the treating physician, the adjuster, and in some cases, an assigned nurse case manager.

CLAIMS PROCEDURE

• Promptly return the following forms to the Third Party Administrator (TPA will provide forms):
  • Medical Authorization
  • Medical Provider Information including preferred Pharmacy
  • Affidavit of No Insurance (when applicable)

  In addition, the following information must be furnished to the TPA:

  • Copy of employee’s health insurance ID Card.
  • Explanations of Benefits (EOB’s) provided by the insurance company.
  • Receipts for any out-of-pocket expenses incurred such as co-pays, deductibles or over-the counter medication expenses, etc.
  • All correspondence should include – employee’s name, the name of the TPA adjuster and the claim number assigned to the individual claim.

  Employee is encouraged to retain copies of all EOBs, receipts or other expense records sent to the TPA.

COVERED EXPENSES AND BENEFITS

• Medical fees including copays, deductibles, and other out-of-pocket expenses not covered by personal health insurance.
• Prescription and over-the-counter drugs (prescribed by the treating physician and related to the on-the-job injury/illness) expenses not covered by personal health insurance. Employees may use any pharmacy of their choosing but are encouraged to utilize the AU Employee Pharmacy, the AU Student Pharmacy at the AU Medical Clinic or a BCBS preferred pharmacy.
• Mileage costs are reimbursed for incurred travel to and from medical and rehabilitation providers at the same rate as provided for official state travel.
• Lost Wages benefits are paid at the rate of 66 2/3 % of the employee’s regular rate of pay, not to exceed the maximum weekly rate set annually by law. OJI lost wage benefits are subject to federal and state tax deductions, and all other personal deductions. Reduced earnings (66 2/3%) paid under the OJI program may affect retirement benefits. Contact a Payroll and Benefits representative at 334-844-4183 or email at payroll@auburn.edu to discuss in more detail.

PROCEDURES TO RECEIVE OJI LOST WAGE BENEFITS

• To receive lost wage benefits for time missed from work, the employee must provide the TPA adjuster and their AU supervisor a statement from their treating physician certifying disability from work is a result of a work injury or illness.
• The first three days off work are considered a waiting period and no lost wage benefits will be paid during this time. An employee may request to use available annual or sick leave during this waiting period.
• The employee must notify the person who prepares payroll in their division/department that they wish to apply for OJI lost wage benefits. Or, the employee may elect to use accrued annual or sick leave during the disability and recovery period. The OJI Program makes no provision for replacement of personal leave time taken for any days absent due to a work related disability.
• The employee must advise their supervisor of how they wish to be compensated for time missed from work so payroll administrators can make proper entries in Kronos and OJI timesheets can be completed.
• With each subsequent physician appointment, the employee must provide the TPA adjuster and their supervisor a statement certifying their continued disability from work.
• The OJI Program provides lost wage benefits for the initial 180 days (26 weeks) of work related disability. If disability continues beyond that point, the employee should transition to Long-Term Disability (LTD) benefits. If rejected for LTD benefits and unable to return to work, as authorized by the treating physician, the OJI program can provide up to an additional 180 days of lost wage benefits. The maximum lost wage benefit period is 360 days.

Auburn University Retains the Right to Assert Claims on Responsible Third Parties.

CONDITIONS OF PARTICIPATION

As a condition of participation in the OJI Program and the receipt of benefits, the employee acknowledges and agrees that payment of any benefits does not preclude Auburn University from asserting a claim for recovery of all sums paid by Auburn University under the OJI Program on behalf of an injured employee from any third party, who may be responsible for the injuries or occupational illnesses sustained by that employee.

DISPUTING ELIGIBILITY OR DETERMINATION OF OJI BENEFITS

The time limit for filing a claim before the State of Alabama Board of Adjustment is one (1) year and “begins to run from the time of the happening or occurrence which later produced the disability, not from the time a compensable injury or disability becomes apparent”.

The procedures and forms for filing a claim with the State of Alabama Board of Adjustment can be found online or by calling the Board at (334) 242-7175 for assistance.