The vendor is required to provide to secure the professional services of a third-party claim’s administrator to provide comprehensive claims administration services, including but not limited to workers’ compensation, casualty and property claims, loss analysis and reports, and on-call emergency field investigation response.
1. Workers’ compensation claims
• Receive, process, accept, or deny claims in accordance with statutory guidelines based on thorough investigation and analysis of medical and factual information. prior approval from the water authority is required before denying a claim.
• Review and process all claims and loss reports in compliance with applicable laws.
• Prepare and submit all required forms and notices to claimants, the water authority, and the n division of workers’ compensation within statutory deadlines.
• Establish and maintain claims files, conduct necessary investigations, and communicate with claimants as needed, including obtaining recorded statements for lost time and contested claims.
• Document all claim files, including communications with claimants, attorneys, medical providers, and other stakeholders, ensuring act compliance.
• Establish and maintain reserves based on probable final costs, reviewing reserves quarterly. adjusters should wait for medical bills, records, and a completed evaluation before setting reserves, unless preapproval is obtained from the water authority.
• Pay indemnity benefits timely and obtain medical verification before issuing payments for ongoing disability.
• Provide bill review services for questionable medical expenses.
• Review claim files monthly for closure, providing reports to the water authority risk manager.
• Outline claim strategies, including defense approaches, independent medical examinations, and ancillary medical services, subject to water authority authorization.
• Coordinate with water authority-selected litigation attorneys on case strategy.
• Obtain water authority pre-approval for settlement offers and acceptances.
• Assist water authority’s legal counsel by internal and external with claim defense, including forwarding claim files as necessary.
• Investigate and pursue subrogation claims where applicable.
• Attend hearings, mediations, and meetings as required.
• Provide medical case management services, including nurse case management.
• Notify insurance carriers regarding excess coverage attachment points per policy terms.
• If a claim has the potential to exceed 50% of the self-insured retention (sir), the contractor must notify the carrier promptly.
• Provide remote access to claim file notes for water authority personnel.
2. Casualty and property claims
• Evaluate claims for coverage under water authority’s insurance policies.
• Investigate claims to determine liability based on applicable laws, including the state tort claims act, contract liability, and federal statutes.
• Adjust, settle, or deny claims within discretionary settlement authority limits or with water authority risk manager or attorney approval if exceeding stated limits.
• Coordinate with water authority-selected attorneys on litigated claims.
• Work with insurance carriers and attorneys on claim investigations and settlements.
• Report claims to excess carriers per policy requirements and monitor recoveries.
• Maintain and update claim reserves with quarterly supervisor review.
• Pursue subrogation where applicable.
• First-party property damage claims may be submitted for subrogation recovery efforts, with all recovered amounts payable to the water authority.
• Document all claim-related communications and provide remote access to claim file notes.
• Provide online claim reporting capabilities.
3. General requirements
• Provide online claim reporting and remote system access to the water authority.
• Deliver monthly reports identifying claim trends and recommendations to reduce future exposures.
• Ensure compliance with all state and federal privacy laws, including act.
• Allow water authority’s internal audit department to conduct compliance audits during normal business hours.
• Maintain clear documentation of resolution disposition strategies in claim files.
• Return all phone calls and emails within 24 hours.
• Provide water authority updates on all claim status changes, including settlements, releases, and denials, g-mail or by phone.
• Supervisor assignment notes must be documented within 30 business days of claim receipt, with follow-up reviews conducted within 30-90 days.
4. Loss analysis and reports
• Provide required notifications to insurance carriers regarding excess coverage concerns.
• Generate computerized loss reports summarizing all claims, including claimant details, department, cause of loss, and financial breakdowns.
• Maintain an updated quarterly summary of all open and closed claims.
• Record all payments on uninsured claims for experience tracking.
• Provide detailed monthly financial check registers.
• Submit necessary data for the water authority’s workers’ compensation self-insured reporting requirements.
• Schedule and coordinate quarterly claim review meetings with water authority personnel.
• Track and report medicare set-aside obligations.
• Maintain a database of all claim data, ensuring water authority access.
5. On-call emergency field response
• Provide 24/7 emergency field response/coverage to water authority customers impacted by operations. respond promptly to call-outs for water authority incidents and accidents.
• Gather claim file information, complete required field response documentation, and assess property damage.
• Assist affected property owners in accordance with water authority guidelines.
• Coordinate with the water authority dispatch team at 505-842-9287 to provide an estimated response time for emergencies.
 • In cases involving significant damages exceeding or that can potentially exceed $100,000 or questionable liability, the adjuster must consult with a supervisor and the water authority before proceeding cleanup restoration or reconstruction coordination activities.
6. Transition services
• Provide transition services, including setting up files, system testing, and coordination with the predecessor (third party administrator) TPA, for a period of thirty (30) to ninety (90) days before services commence.
• Facilitate claim data migration from the current TPA and reclassification of claims as necessary.
• Assist in the transition of obligations to a successor TPA upon contract completion.
7. Continuing obligation
• For ninety (90) calendar days following contract completion and claim transition, the contractor shall continue to provide necessary support, without additional charge, until all water authority assets, programs, and funds are successfully transferred to the successor TPA.
- Contract Period/Term: 4 years