Workers Compensation Claims Third Party Administrator Services

The Vendor is required to provide licensed workers’ compensation third-party administrators (TPA) for claims administration services for the insolvency fund for self-insured employers and the insolvency fund for self-insured associations.
- Program Development and Maintenance
•    TPA will administer workers' compensation claims of insolvent SIES and SIAS, including, but not limited to claim management and administration; case management; bill review; excess insurance recovery; subrogation; payment; and settlement in consultation with division staff and in accordance with applicable state laws.
•    TPA will assume the complete handling of all open and reopened claims as well as new claims, accepted by the division and assigned to the contracted TPA, of insolvent SIES or SIAS, whether currently insolvent or determined in the future to be insolvent, from the effective date of this contract. Division approval is required before a new or reopened claim may be paid by either fund. 
•    TPA will ensure that requests for all outside case management services utilized, including, but not limited to, nurse case management and special investigation services, must be discussed with and approved by the division in advance.
•    TPA will ensure that prior to reopening any previously closed claims, the adjuster must provide and discuss the rationale with division staff. 
•    Within thirty (30) calendar days of the award of the contract, with input and agreement of the division, the TPA shall develop a claims handling protocol document delineating handling of claims in the following areas: processing claims; issuing timely claim determinations; managing medical treatment; providing litigation support; establishing and maintaining reserves; maintaining accurate and timely payment of bills to ensure no duplicate payments; and providing timely payment of any and all workers’ compensation benefits. 
•    The document should also include TPA staff contact information, expectations and process descriptions.
•    TPA will ensure a list of treating providers is filed with the department in accordance with any subsequent legislative changes. 
•    TPA shall produce an electronic copy of a claim file at the request of the division.
•    TPA will comply with all state and federal laws and adhere to all state and federal reporting requirements.
- Claims Management Information System
•    TPA will import from the prior vendor and convert all historical data, documents and financial elements of both workers’ compensation insolvency funds’ open and closed claim files into its electronic claims system. It is required that claims data and all other documentation associated with all current and prior open and closed claims be transferred into TPA’S electronic claims system to ensure future loss runs will contain a complete history of all claim years. Transfer of all claims, data, information, or files must occur within the first 30 days of the contract’s start date.
•    TPA will assume responsibility for the transfer from the previous vendor of all electronic open and closed claims, while maintaining claim file completeness, coherence and integrity.
•    TPA will enhance or modify its claim handling software, as needed, to administer claims. All refinements, updates and modifications to the claims management information system will be at the expense of the TPA.
•    TPA must maintain proper claim file documentation electronically, including but not limited to: claim activities, events, actions, and claim facts; action plans; activity logs or diary notes; supporting imaged documents; calculations of indemnity benefits; temporary modified/light duty actions; TTD, TPD, VR maintenance and permanent total disability (PTD) payments; overpayment and underpayments; excess reimbursement requests and recoveries; and subrogation. 
•    TPA shall electronically maintain imaged claim documents, in chronological order, to include all correspondence, written determinations, department mandated forms, all litigation documents; medical reports, medical bills and explanations of benefits that were created when bills were paid in chronological order.
•    TPA will ensure that required data, documentation, and payments are posted to each claim file in an accurate and timely manner.
•    TPA will ensure that reopened claims shall be fully integrated into the electronic record. 
•    TPA will store claim files electronically for the life of the contract. Upon termination or nonrenewal of this contract, TPA will turn over all claim records and files, regardless of format, to the division or to a vendor designated by the division. 
•    TPA shall provide the division or its new vendor with the necessary assistance to complete a smooth transition and provide the division final computerized reports in a format which is usable and agreed upon by the division, providing claims listings, total amounts spent, and other loss information as required. In addition, TPA will comply with all applicable laws and regulations pertaining to insurer and third-party administrator claims file transfer obligations. 
•    TPA will not destroy files relating to the claims subject to this contract.
- Claims Administration
•    TPA will review and process all claims for workers’ compensation benefits in accordance with requirements of state law.
•    TPA will provide written notification to claimants regarding the transition of the claim to the tpa upon start of contract and upon subsequent assumption of additional insolvent claims by the division.
•    TPA will assign a dedicated and appropriately licensed claims adjuster to handle the SIE and SIA claims.  
•    TPA will provide written notification to the division of a change in this adjuster as well as the adjuster’s direct contact information within thirty (30) days of the change.
•    TPA will assume responsibility for the administration of all claims assigned by the division to one of the funds after the effective date of the contract.
•    TPA will ensure that all claims, including medical claims only and lost time claims, shall be thoroughly investigated to determine compensability and include contact with the employer, injured employee, witnesses and treating physician.
•    TPA will review all medical invoices, obtain additional information or corrections as needed to ensure that services are correct and compensable for the accepted injury or disease, and fees have been reduced to the state medical fee schedule and a managed care discount has been applied, where applicable. 
•    TPA will promptly review, compute and timely pay all benefits, rating awards, medical and indemnity payments, in accordance with state law.
•    TPA will arrange and supervise rehabilitation programs, assigning rehabilitation service vendors when appropriate.
•    TPA will promptly establish reserves on claims based upon medical and factual reporting, anticipated medical treatment, anticipated length of temporary disability, expected permanent residual impairment, age and occupation of the worker, anticipated indemnity or survivors’ benefits, and state law. Reserves shall be established based upon the potential cost of each claim. 
•    Any changes to reserves shall include an explanation for the change. 
•    All reserves categories shall be reviewed on a regular basis but at least every ninety (90) days. Such reserves shall be indicated in the claim notes.
•    TPA will inform and consult with the division regarding excess insurance recovery and subrogation, file reimbursement requests with the insurers, and copy the division on all filings with insurers regarding reimbursement requests and any other subrogation. 
•    TPA will follow up with excess insurers to ensure reconciliation and reimbursement of the requested amount to the appropriate Fund.

- Contract Period/Term: 4 years
- Questions/Inquires Deadline: October 22, 2025