Third-Party Administration (TPA) Workers Compensation Claim Services

At Constitution State Services, we believe every injured employee should have a personalized recovery experience. Our dedicated Claim professionals and nurses ensure every injured employee receives prompt and appropriate treatment, while our industry-leading practices and resources help contain claim costs. We also align our capabilities to the unique demands of your business, meaning you only pay for the services you need.

With an average of 13 years experience,³ Constitution State Services Claim professionals bring the stability and expertise to deliver optimal workers compensation outcomes. Our high employee retention rates enable our Claim professionals to integrate with your team and intimately understand the needs of your business.

At CSS, we invest in our people and their careers. The CSS learning center serves as a hub of in-person, virtual and just-in-time training to continually grow our Claim team’s skills. Using real-world simulations, CSS Claim professionals learn technical fundamentals and develop skills to effectively engage with customers, brokers and business partners.

Data-driven analytics allow us to align the right team member with the right claim, striking a balance between effective claim management and cost efficiency. CSS collects structured and unstructured data generated from 30 million medical bills and 2 billion claim notes. This data fuels reporting via e-CARMA^®, our top-rated⁴ risk management information system you can use to monitor the status of claims, evaluate trends and measure our performance as your third-party administrator. Our predictive models and analytics tools include:

• A workers compensation fraud model that uses machine learning technology, increasing our fraud identification rate by 20%.⁵
• Automated social listening tools search publicly posted content for signs of fraud, including injured employee’s physical activity, employment, prior injuries and more.
• A nurse assignment model that continually monitors the severity of a claim to help determine the optimal time for nurse medical case management involvement.
• Subrogation triage model that helps us pursue every reasonable opportunity for recovery.

CSS is innovating TPA services to provide the best care for injured employees at the lowest cost available. Using CustomCare^SM, a cutting-edge claim management process, employers and their injured employees benefit from a balance of digital self-service and personal connections that enable better workers compensation claim outcomes.

• Nurse Triage Model helps determine the appropriate level of care.
• ConciergeCLAIM^® Nurse program co-locates a CSS nurse for a face-to-face experience.
• Virtual Visit allows injured employees to have real-time video chats with our Claim and medical professionals.
• Early Severity Predictor^® helps us identify injuries that could cause employees to suffer from chronic pain. Having insight about who may be at risk to develop chronic pain can help injured employees avoid the dangers of opioid addiction and can help companies reduce growing workers compensation loss costs.

Our industry leading investigators work closely with CSS Claim professionals to detect, investigate and deter fraudulent activity and help support accurate evaluation of claims. For cases of potential fraud, our investigative services team conducts interviews and obtains surveillance video, among other investigative strategies. 

• We have more than 300 highly skilled investigators across the country, 75% with prior law enforcement training.
• Specialized resources for prosecution and surveillance help ensure optimal results.

Injured Employee Portal

We offer a secure, web-based tool to help injured employees navigate the workers compensation claim process. It features ePay enrollment, two-way document sharing, FAQs and secure messaging with the CSS Claim team.

Nurse Case Management

Working alongside Claim professionals, our staff nurses ensure your injured employees are fully supported throughout their claim and recovery. We focus on more than just the physical injury and address both psychological and social factors that may inhibit recovery. 

Virtual Visit

Injured employees, employers and providers have access to real-time video chats with Medical Case Managers and Claim professionals. The tool offers a quick and easy way to collect time sensitive information, such as updates to the file immediately following a medical provider visit and scene photos, which might be relevant to determining compensability.

Early Severity Indicator

This program uses data and analytics to identify which injured employees are at a higher risk of developing chronic pain.

Telemedicine

The TravCare^® Nurse Line allows injured employees to receive immediate medical guidance after an injury. Workers are connected to a nurse who can recommend the appropriate level of care after a workplace injury. This helps the injured employee find the best course of treatment and avoids unnecessary ER visits.