Self Insured Workers Compensation TPA Services

The Vendor is required to provide third party administrator (TPA) for its self-insured workers’ compensation program to perform claims administration services, including Medicare section 111 mandatory reporting, and to administer and provide ancillary services, which may include bill review, medical case management, utilization review and a medical provider network.
- Workers' compensation claims standards
1. Investigation
•    Within three (3) working days of receipt of the self-insurer accident report ("sif-2"), contact will be made with the employer in order to determine if compensability is to be acknowledged or questioned when not self-evident on the sif-2.
•    On all questionable indemnity cases, informative statements will be obtained from anyone who may have knowledge of the injury, including the claimant, witnesses and supervisor, within ten (10) calendar days of receipt of the sif-2, unless the file reflects a reasonable explanation for a delay in obtaining same.
•    Medical documentation (time loss certification) will be obtained within five (5) working days of the first day of lost time and as often as needed thereafter to justify continuing indemnity payments.
•    Personal contact on non-litigated indemnity cases will be maintained with the injured employee on a periodic, ongoing basis (initial, within 3 days of receipt of sif-2 and follow-up within every 14 days thereafter until return to work) to control their medical progress and timely return to work.
•    All investigations will be coordinated with appropriate district personnel on a case-by-case basis.
•    Medical evaluation is questioned, an independent medical examination will be scheduled with a qualified physician, providing to the physician any relevant medical and job information that will assist the physician in making an objective evaluation.
•    Any medical bills received will be reviewed prior to payment to determine a causal relationship between the bill and the accident and work-related injury that is the basis of the claim.
•    All reserves will be evaluated for accuracy, based on information at hand, every time the case is handled and reviewed. 
•    All "medical only" cases will be reviewed for closing at least every 60 days.
2. Processing requirements
•    All files will be created, reserved, properly coded as to location, department and bargaining unit and entered into the system promptly upon receipt of the first report. 
•    Payments will be made promptly, within mandated timeframes. 
•    All payments, reserve revisions and file closing will be promptly entered into the computer system. 
•    All indemnity injuries will be reported to the index bureau as soon as possible upon receipt of the sif-2. 
•    A case management diary system will be established so that each case is reviewed at least every thirty (30) days or more often where needed, as directed by the TPA or the district. 
•    All reports, forms, and other documents required under department of labor and industries regulations must be prepared and filed on behalf of the district. 
•    Reserves will be established and maintained taking into consideration all potential payments including allocated expenses.
3. File documentation requirements
•    The basis for all initial reserves, reserve revisions and payments will be clearly documented in the file. 
•    Specific direction on the investigation and handling of all indemnity cases will be established and clearly evidenced in the file. 
•    The extent of the direction will be clearly based upon the seriousness or complexity of the case at hand. 
•    An initial file summary will be competed on all indemnity cases involving temporary total disability (TTD) or loss of earning power (LEP) payments within ten (10) days of receipt of the first report.
•    All phone conversations, discussions and meetings held on the case will be clearly documented in each file
•    The diary schedule will be clearly evidenced in the claim record.