Insurance Claim Review and Audit Services

The Vendor is required to provide professional insurance claim audit services to review claims files managed by agency third party administrator (TPA) pursuant to its discretionary purchasing authority under state finance law §163(6).
- All the information made available on each case selected for review, with an understanding of the state workers’ compensation rules and regulations.
- Offer a recommendation as to what the indemnity (compensation) and medical incurred losses should be for each case reviewed and present same on a spreadsheet.
- Review and evaluate claim adjustments for appropriate and accurate payment;
- Provide a concise summary of the claim reviewed along with a rationale for the incurred values recommended (to include calculations);
- Provide direction and guidance on claims handling issues if warranted;
- Re-evaluate recommendations if provided with additional information from the administrator;
- Prepare a summary report to include statistical information on incurred losses and findings and recommendation;
- Verify that reserve recommendations are reflected in the administrator’s claims program and report to agency reserve recommendations not adhered to;
- Verify that claims handling recommendations are addressed by administrator and report to agency recommendations that are not adhered to.
- Contract Period/Term: 5 years
- Questions/Inquires Deadline: July 14, 2025