Third Party Claims Administrator Services

The Vendor is required to provide third-party claim administrators; hereinafter referred to as “TPA”, for administration of the self-insured workers’ compensation claims.
- The risk management division oversees the TPA and all aspects of the program including: investigations, claims adjustment, reserving, maintenance of claim files, and legal support services.
- Consultant shall perform the following services as a third-party administrator (‘TPA”) for administration of city self-insured worker’s compensation claims.
- Claims management services
• Make initial contact via phone and email with the employee and establish a claim file within 24 hours of receipt of the employer’s first report of injury for the city.
• Claim files will be available for review by the city at any time during the consultant’s regular business hours.
• Contact city employees via phone and email or in-person to explain the department benefit notices and other required letters and forms; in addition, the consultant will provide guidance and information regarding workers’ compensation benefits to city employees.
• Via the online claim system or via email provide copies of all correspondence to the city that is sent to employees on the same day the original is sent to the employee.
• Via email or phone, respond to city staff inquiries within twenty-four (24) hours or the next business day and critical issues on the same day.
• Monitor treatment programs for injured employees to ensure that they receive proper care and to avoid over-treatment situations.
• Meet state law utilization review, independent medical review and medical provider network guidelines and standards.
• Consultant shall guarantee compliance with federal and state law and industry guidelines.
• Establish adequate claim reserves and provide a continual review and update of reserves to reflect changes during the life of the claim.
• Administer workers’ compensation benefits in accordance with the labor code, union contracts, and any other legal requirements; consultant shall guarantee compliance.
• Maintain accurate loss runs in a format and timeframe that is acceptable to the city.
- Catastrophic claims include
• Amputations
• Serious disfigurement
• Quadriplegic/paraplegic
• Serious burns
• Brain injury
- Proceed against responsible third parties in subrogation actions to recover losses suffered by the city due to payment or workers’ compensation benefits.
- Investigate and recommend special, outside investigations for questionable claims with the coordination and assistance of risk management.
- Provide advance notice and explanation to the risk management division of any claim for workers’ compensation benefits that is contested and may be denied by the third-party claim.
- Ensure that the city complies with all medical provider network notice requirements.
- Contract Period/Term: 3 years
- Questions/Inquires Deadline: April 01, 2025