Third Party Claims Administration and Related Services

The vendor is required to provide for third party administrator (TPA) services partnership which deliver objective and measurable results that will reduce the cost and duration of worker's compensation claims, provide claims processing in a timely and professional manner, actively pursue subrogation, assist in returning injured employees back to work and maintain strong communication with injured workers and the county.
- TPA will be responsible for providing or working with contractor to provide the county with a comprehensive program designed to contain the medical costs in county's workers compensation program. 
- These services shall include, but are not limited to:
• Medical bill review
• Rehabilitation services
• Hospital bill auditing
• Pharmacy bill auditing
• Prescription management services (normally provided by the cost containment company)
• Annuity costs
• Billing payment program
• Pre-authorization services
• Medical peer-review services
• Certified workers' compensation network/504 program
- TPA shall provide a toll-free telephone number for the county and claimants.
- Provide on-call staff information for emergencies. 
- This contact shall be available to the county at all times, during non-business hours.
- TPA shall make recommendations regarding the county's claims processes and procedures.
- TPA shall cooperate completely with the county, county's risk consultant and adjusters/attorneys.
- TPA shall respond to inquiries within one (1) business day.
- TPA, at no additional cost to the county, agrees that the county shall have reasonable access to all claim files.
- The ability to have real time and immediate access to your web-based claims system.
- TPA, at no additional cost to the county, must provide county employees (injured workers) access to claims staff.
- 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 inform county about new legislation, rules, landmark appeal or court decisions for indemnity and medical issues and advice of the potential impact to the county's workers' compensation program and how these may affect the handling of claims.
- TPA shall facilitate a smooth transition of administrative services and claims history from the current contractor and to any subsequent contractors.
- TPA shall provide accurate, timely and responsive administration of all workers' compensation claims filed by county employees.
- TPA shall provide on-going management of claims in a manner that provides high-quality, cost-effective benefits and superior customer service to injured workers and county human resources department.
- TPA shall provide on-going coordination and collaboration with the county human resources department and other providers to ensure consistent claim management.
- TPA shall have a customer service toll-free phone line available and fully operational to provide information to county and employees.
- TPA must discuss all the reasons of denial with the county's risk manager.
- All claims will be documented regarding compensability
- All medical only claims involving work restrictions will be handled the same as lost time claims as respects diary, medical management and release to regular duty
- Reserves, including reserve worksheets, must be reviewed upon diary and reserve analysis must be documented in the reflecting of all reserve changes
- TPA will be responsible for liens and subrogation of money for parties at fault.
- TPA will perform all work on claims, with the exception of legal services.
- Account manager and/or supervisor shall create a claim file workflow to ensure timely claim processing and handling.
- TPA will attend other meetings and/or hearing as required by the county and as necessary.
- TPA, at no additional cost to the county, shall provide access to claim's system at county offices for no less than 3 users and provide the attendant training and support
- The access shall allow the creation of ad hoc reports as well as the standard package of system reports.
- TPA, at no additional cost to the county, shall make the necessary document filings and/or electronic submissions to satisfy the county, and any and all state and federal mandates, requirements, or law.
- Import all prior loss data into a single database.
- Imaging system to scan all documents received related to the claim.
- TPA must have the ability to export claim data into various Microsoft products, i.e. word, excel, power point.
- TPA will provide RMIS technical support for questions, problems or development of customized reporting.
- claim data shall be real time (preferred) or uploaded every 24 hours.
- TPA shall provide is technical support for questions, problems or development of customized reporting.
- TPA shall provide information needed to prepare county annual status reports and actuarial reports as required by the county.
- TPA shall provide monthly medical bill savings reports.
- TPA shall provide monthly provider utilization reports.
- TPA shall provide monthly pre-authorization reports.
- TPA shall ensure that all data in the entire system is adequately backed up with at least daily back-ups on site by at least two (2) machine readable formats and weekly backup’s stored offsite.
- Contract Period/Term: 5 years
- Pre-Proposal Meeting Date: June 24, 2025
- Questions/Inquires Deadline: June 27, 2025