The vendor is required to provide consist of claims administration, claims monitoring, medical case management, utilization review (UR) according to 452 CMR 6.0 et AI, vocational rehabilitation case management, and medical case management to and through resolution of all active past, current and future claims and cases.
- The services shall include: receipt, processing, filing and maintenance of all claim-related forms, reports and notices as required by state law for controlling losses; utilization review (UR) and verification of all medical services billings, including medications and durable medical equipment, and determination of lowest state authorized rate for payments by the contractor on behalf of the town, including claimants granted accidental disability retirement (ADR); timely follow-up with doctors and claimants and investigation of cases, when necessary, to reduce exposure and cost; management of return to work and modified work programs; vocational rehabilitation case management; and recommendations of appropriate claimant's earning cape town status for final decision by the town.
- Legal services
• The service provider will offer education and training on interpretation and application of related legislation, various procedures, and case law.
• The service provider will identify claims with subrogation potential, will assist in placing notice of lien, and will monitor status of such claims.
- Medical reports
• All medical and rehabilitation reports, office notes, test results or the like from all treating physicians, chiropractors, physical and occupational therapists, clinics, hospitals, or any other providers deemed necessary by the town.
- Claim handling:
• Confirm claim as lost or no lost time or medical only,
• Establish liability reserve for compensation and medical services for each claim,
• Establish claim status for payment or non-payment pending further review,
• Classify claims as report only, first aid only, medical only, or lost time/indemnity,
• Medical case management, including utilization review (UR), and treatment performance monitoring;
• Application of medical cost containment initiatives (e.g., pre-approval for medical services, medical services and pharmacy bill review for justification and payment, utilization review (UR), the use of the lowest state rate setting fees and negotiated fees approved by the town, etc.);
- Contract Period/Term: 1 year
- Questions/Inquires Deadline: April 14, 2025