Compensation and Liability Third Party Claims Administration Services

The vendor is required to provide for a qualified firm worker's compensation and liability third party claims administration (TPA) services interested in contracting with the district for professional claims administration and risk management services for the district's self-funded worker's compensation and liability program.
- TPA responsibilities
• TPA shall aggressively manage all workers’ compensation claims presented by the district according to the professional standards of the firm and the district’s requirements, and to act as the district’s representative in matters relating to workers’ compensation laws of the state.
• a copy of the TPA’S professional standards, including turnaround-time benchmarks, must accompany your proposal.
• TPA shall make recommendations regarding the district’s claims processes and procedures.
• TPA shall make settlement recommendations to district and act promptly on district’s instructions.
• TPA shall cooperate completely with the district, district’s insurance broker and other adjusters and attorneys of the district’s excess insurance carrier.
• TPA shall respond to inquiries within one business day.
• TPA shall cooperate fully with directions given by the district’s sole broker of record on the district’s behalf.
• TPA shall cooperate with any medical cost containment, case management, investigations, law firm, or any other organization designated by the district.
• TPA shall proactively search for claim trends and notify the district as they appear.
• Medical cost containment services shall be provided by the TPA, or outsourced by the TPA to a medical cost containment provider.
• Proposer may submit up to two options with proposal; however, the “pricing/fee schedule” form
must be submitted for each option.
• Prescription benefit management (PBM) services shall be provided or outsourced by TPA.
• For services sub-contracted out, TPA shall be the managing contractor.
• TPA shall disclose any commissions and/or any other type of compensation received from the sub-contractors.
• TPA shall act as the district’s designated reporting agency (ra) for mandatory reporting of medicare
• Medicaid, and SCHIP extension act of 2007, or other similar successor laws.
• TPA will be responsible for any fines and/or penalties levied by the department of insurance or other regulatory body for any matters within the TPA control.
• TPA will meet with the district’s assistant director of risk management, at a location of the district’s choosing, at least quarterly to review the status and/or handling of all open claims and any other matters at the discretion of the district.
• The TPA shall conduct an annual stewardship meeting and provide a formal stewardship report.
• TPA shall allow the district the opportunity to participate in regular training sessions or seminars held for its servicing personnel.
• TPA shall provide the district with full access to its own claim information within the claims information system and database, including the ability to view claim notes, produce reports, charts, graphs, etc.
• TPA will indemnify and protect the district against errors or omissions committed by the TPA .
• TPA agrees to hold the district harmless and to indemnify the district for all loss arising out of any claims alleging an error or omission with respect to the services performed by the TPA .
• TPA shall designate one individual as the primary contact on items not directly related to specific claims.
• TPA shall ensure that secondary contacts are available in the event of the primary contact’s absence.
• TPA shall supply a list of all potential servicing personnel with a current resume of the designated adjuster(s) and backup adjuster who will handle district claims.
• Any additional personnel to be involved in district claims handling at a later date should have a resume submitted for prior consultation with the district.
- Claims processing
• Files will be created and assigned by the TPA within one (1) working day from receipt of the initial report.
• Contact with claimant and the district by the TPA will be within one (1) working day from receipt of initial report for all indemnity claims and two (2) working days for all bodily injury liability claims.
• The TPA will utilize the same injury codes, classification codes and departmental codes as the district’s current system unless a change is authorized by the district.
• Upon knowledge of a catastrophic claim, notification will be made immediately via telephone by the TPA to the district.
• These types of claims would include: fatality, amputations, serious burns, brain injury, multiple injuries. senior personnel will be directly involved with any catastrophic claims.
• Diaries will be established by the TPA so that each case is reviewed at least every thirty (30) days, or as needed.
• The TPA will prepare and maintain files necessary for legal defense of claims and/or litigation.
• All claims reported under the contract, including record only, medical only, indemnity, an subrogation will be administered until fully settled, regardless of the period of time involved or required, in accordance with the fee structure indicated in the contract for services.
• Settlement of any claim requires the approval of the district’s assistant director of risk management.
• TPA or an outside agency approved by district in writing will audit medical bills for causal relationship and reasonableness of charges.
• The TPA will report all indemnity cases to the index bureau upon file creation, and a copy will be retained with the file, at no cost to district. medical only claims will be reviewed by the TPA for possible closure no less frequently than every thirty (30) days.
• Where appropriate or desirable, the TPA will attend hearings, depositions, mediations, and other proceedings.
• The district will not pay expense to attend hearings.
• The expense must be included in the TPA fee.
• The TPA will aggressively pursue all possibilities of subrogation, excess insurance reimbursement, and third-party liens.
• On all claims reserved in excess of $25,000, periodic written reports, at least bi-monthly, will be provided by the TPA to district accompanied by any pertinent file materials.
• As an alternative, TPA shall have the ability to submit reports electronically through the information system (is).
- Reserving
• Reserving will be estimated and maintained by the tpa on the basis of most probable final cost.
• Reserves will be established and reviewed every thirty (30) days.
• The basis for the initial reserve and any reserve revisions will be clearly documented by the tpa for each file.
• For reserves, the TPA will take into consideration the categories of indemnity, medical, rehabilitation, and allocated expenses, and all major sub-categories of each.
• Changes in reserves must be accompanied by a TPA supervisor's approval.
- Investigation and case management
• Initial contact with indemnity claimants will be accomplished or attempted by the TPA prior to the initial compensation unless the claimant has returned to work.
• Claim profiles will be prepared on all claimants with two (2) or more prior workers' compensation indemnity claims.
• Adjuster will actively work with medical professionals, employee, and district to enhance district's return to work program.
• All contacts and attempts to contact claimants will be fully documented by the TPA.
• Prior to all initial payments of temporary income benefits, unless a medical report has been received, the medical provider facility will be contacted by the TPA to establish extent of injury, causal relationship to the alleged incident, and estimated return to work date.
• On all questionable workers’ compensation cases, recorded or informative statements will be secured by the TPA from the claimant, supervisor, witnesses, and any other pertinent parties, and district's risk management department within two (2) working days of receipt of initial report.
• Any workers' compensation claims to be controverted by TPA must be submitted in a caption report form to the district for review.
• The TPA will obtain medical reports will be obtained as frequently as needed for verification of continuing indemnity payments.
• Prior to each indemnity payment, TPA will confirm continued disability with district, provide status information, and discuss availability of modified duty and part time work.
• Telephone or personal contact will be maintained by the TPA with temporarily disabled employees and their supervisor or other district-designated person(s) at least weekly, to maintain rapport and to monitor medical progress, return to work status and modified duties.
• Surveillance should be considered by the TPA where length or extent of temporary disability is questioned.
• Outside investigation services will be employed only when necessary and approved in writing by district.
• The TPA will provide direction and control over the investigator's activities.
• Independent medical examinations will be scheduled by the TPA with qualified district approved physicians in cases where treatment, length of disability or extent of permanent impairment assigned is in question.
• This process will include coordination with the case manager.
• The TPA will ensure personal delivery of any documentation needed in order for any required medical exam (RME) to be completed, at no additional cost to district.
• pertinent past medical records will be secured and apportionment addressed by the TPA in all cases, prior to final resolution of permanent partial disability, impairment income benefits or supplemental income benefits.
• The TPA will arrange vocational rehabilitation when approved in writing by district.
• benefit payments will comply with maximum medical improvement and impairment and supplemental income benefits of the department.
• The TPA workers' compensation manager will approve these payments and this information will be submitted to the assistant director of risk management, or designee, for review and comment in a timely manner.
• Case management will be assigned according to criteria established by the district and TPA, the cost will be charged to file.
• Case management costs will be tracked. on a quarterly basis, a report will be provided to district by TPA.
- Litigation management
• Coordinate investigations on litigated claims with attorneys approved by the district and, when appropriate, with adjusters and attorneys of the excess insurance carrier.
• Provide proper and complete documentation of claim and investigation to legal counsel.
• Review all attorney bills to reconcile hours and rates charged by council to assure they are appropriate for work performed and consistent with any fee arrangement and litigation management programs with district or TPA.
• Provide risk management at least five (5) business days, advance notice of all hearings, conferences, or court dates.
- Financial procedures and claim payment
• The TPA will make workers’ compensation payments promptly and in accordance with the workers' compensation statute.
• Any duplicate payments or overpayments made due to TPA oversight or negligence shall be the responsibility of the TPA will reimburse district for same, within thirty (30) days.
• In addition, TPA will provide district an overpayment report by type, reason, payee, and by fiscal year on a quarterly and annual basis.
• TPA will issue checks from a zero-fund balance account funded by the district.
• Checks will be issued at least weekly with TPA providing a weekly check register electronically to the district business services and risk management.
• The TPA will monitor and collect all recoveries due the district.
• The TPA will advise the district at least quarterly, on the status of outstanding checks so the TPA may determine whether payment(s) to any payee should be voided and reissued or be processed as unclaimed property.
• The TPA will furnish the district with monthly summaries of the bank account and expenditures, including a list of all checks, vouchers, and voided check, in numerical sequence.
• The TPA will prepare and submit IRS form 1099 for all vendors and mail the forms to vendors.
• Proposer will prepare and submit IRS 1099 data electronically no later than January 15th of each year to district.
• The TPA will provide an internet-based claims system with real-time access 24 hours a day, 7 days a week to report claims, review all adjuster and supervisor claim notes, claim bills, generate loss runs or other pre-scheduled or ad hoc loss management/claim reports.
• The district must have the capability to update claim notes, upload documents, etc.
• The TPA will have the ability to export data into microsoft products.
• The TPA shall have a plan for continued operations and recovery if a system failure is experienced.
• The TPA will provide is technical support for questions, problems or development of customized reporting.
• The TPA will have the ability to import all prior loss data into a single database.
• The TPA will have an imaging system to scan all documents received related to the claim.
• The TPA will disclose any fees associated with this service, including the names of any third party used for this reporting.
• The TPA will provide scheduled loss reports to be sent electronically to the district each month, each quarter and upon request.
• the TPA will provide customized reports and interactive reporting capability (client-created).
• Training in the use of the ins will be provided to district staff.
• Any fee for this should be included in the pricing/fee schedule.
• District shall have all right, title, interest, and ownership to all loss statistics and claim files created as a result of the services to be provided by the TPA.
• TPA shall provide the district with computer media containing all claim data at termination of services.
• Such data shall be made available in a format generally importable into a commonly recognized database for claims administration services.
• If a new provider is selected, the electronic transfer of claims will not be paid for until a satisfactory evaluation of the data has been completed by the district’s sole broker of record.
- Contract Period/Term: 1 year
- Questions/Inquires Deadline: March 19, 2025