Self Funded Workers Compensation Program Third Party Claims Administration Medical Bill Services

The Vendor is required to provide to procure third party claims administration (“TPA”) services, medical bill re-pricing/provider access network services and risk management information systems, in support of the Authority’s self-funded workers’ compensation program
- Provide third party workers’ compensation claim administration and claim management services (“TPA”) and medical bill re-pricing/network access services in a manner designed to ensure processing of all claims in accordance with state workers’ compensation statutes — title 34 and all other applicable laws, rules and regulations, from initial assignment through resolution, payment or withdrawal for all claims.
- The Proposer shall establish and maintain the highest professional level of responsive, cost effective, technologically advanced claims management administration services designed to ensure:
•    Effective coordination of all communications and correspondence between claimants, authority administrative and field personnel, medical/expert providers, as well as the authority’s medical section and legal counsel;
•    Prompt, investigation and pursuit of all claims in a manner designed to minimize litigation and to identify and prevent fraud;
•    Subrogation and second injury fund participation where applicable;
•    Utilization of all medical cost containment resources to ensure the consistent delivery of high-quality medical treatment, evaluation and rehabilitation services at the lowest cost to the authority;
•    Utilization of electronic technology and media to facilitate routine communications (e-mail), real-time access to on-line claim information, and data transfer, so as to enhance the quality and value of the claims management and administration services provided;
•    Provision of timely, meaningful and accurate risk management information for the authority to access, review and utilize in the administration of its risk control program;
•    Prompt response to all inquiries and/or complaints.
•    Prompt and accurate compliance with all federal and state workers’ compensation reporting requirements, including but not limited to, section 111 reporting.
- Claims Intake and Administration
•    Receive and process First Report of Injury (FROI) electronically within 24 hours.
•    Assign a qualified adjuster within 24 hours, providing written notification to the Authority.
•    Initiate three-point contact (employer, employee, treating physician) within 48 hours.
•    Issue formal acknowledgment letters within five business days.
•    Investigate compensability, coverage, and fraud promptly, thoroughly documenting findings.
•    Maintain detailed, consistent diary systems for ongoing claim management, tracking every significant development and action taken.
- Disability Management
•    Conduct regular follow-ups with treating physicians and providers.
•    Monitor employee treatment plans, medical progress, rehabilitation services, and return-to-work projections.
•    Regularly update Authority on temporary and permanent disability cases.
- Medical Management and Cost Containment
•    Administer comprehensive preferred provider networks, regularly updated and geographically extensive.
•    Negotiate discounted rates with providers aggressively.
•    Execute comprehensive medical bill review processes:
o    Verify and match bills with authorization and treatment records.
o    Conduct thorough audits of itemized bills.
o    Confirm billing accuracy and coding integrity.
o    Electronically transmit bills to medical repricing vendors within five business days.
o    Follow up promptly on incomplete medical records or information requests.
o    Ensure medical bills are repriced and paid within ten business days upon receipt of repriced amounts.
•    Implement strict utilization review procedures adhering to accepted medical treatment guidelines.
•    Provide seamless prescription medication management and direct pharmacy coordination.
- Financial Management and Reporting
•    Maintain a dedicated, interest-bearing bank account specifically for Authority claims payments.
•    Ensure detailed monthly reconciliation, account balance verification, and accurate reporting.
•    Provide monthly payment registers and detailed transaction reports.
- Risk Management Information System (RMIS)
•    Deploy a secure, comprehensive web-based RMIS accessible 24/7.
•    Ensure historical data migration without loss or corruption.
•    Provide comprehensive real-time reporting capabilities, including ad-hoc and customized reports.
- Excess and Regulatory Reporting
•    Timely report all claims exceeding $500,000 to excess carriers with detailed narratives.
•    Fully comply with mandatory CMS section 111 and agency reporting requirements.
- Fraud Detection and Surveillance
•    Establish proactive fraud detection measures.
•    Provide robust surveillance and investigative services, including detailed reporting and evidence collection.
- Subrogation and Recovery
•    Actively identify and pursue subrogation opportunities.
•    Pursue Second Injury Fund recoveries diligently.
- Support and Advisory Services
•    Offer continuous 24/7 advisory services for emergency and urgent claim scenarios.
•    Conduct quarterly onsite claims review meetings with detailed reporting.
•    Provide employee training and comprehensive risk/loss control resources.
- Budget: $1,250,000.00

- Contract Period/Term: 3 years
- Questions/Inquires Deadline: August 21, 2025