The vendor is required to provide to perform professional claims administration with support and risk management services for the district's self-funded workers' compensation program.
- Processing-minimum claims standards
• Files will be created and assigned within one working day from receipt of the initial report.
• Contact with claimant will be within one working day from receipt of initial report, either by telephone call or by sending a contact letter.
• Diaries will be established so that each case is reviewed at least every 30 days, or as needed.
• Confirmation of review will be documented.
• Payments will be made promptly and in accordance with the workers' compensation statute.
• TPA or an outside agency approved by the district will audit medical bills for causal relationship and reasonableness of charges.
• All indemnity cases will be reported to the index bureau upon file creation, and a copy will be retained with the file, at no cost to the district.
• Medical only claims will be reviewed for possible closure no less frequently than every 30 days.
• Copies of all written correspondence from the TPA to/from other parties will be provided to the district’s risk manager, or his designee, upon request.
• On all indemnity claims and/or those claims reserved in excess of $10,000, periodic written reports, at least 60 days, will be provided to the district accompanied by any pertinent file materials.
• As an alternative, TPA shall have the ability to submit reports electronically through the tis system.
- Reserving
• Reserving will be estimated and maintained on the basis of most probable final cost and documented by dated and initialed reserved worksheets.
• Reserves will be established and reviewed every 30 days.
• With the exception of medical only claims, reserve worksheets will be completed for all initial and revised incurred loss estimates.
• Reserve worksheets will take into consideration the categories of indemnity, medical, rehabilitation, and allocated expenses, and all major sub categories of each.
• Changes in reserves must be accompanied by a supervisor's approval. - File documentation
• Thoroughly completed reserve worksheets will be contained within all indemnity files.
• All file activity, including telephone conversations or personal meetings and diary reviews will be clearly documented to reflect the date, individuals involved, and content of discussion and plan of action.
• Specific direction on the investigation and handling of all indemnity and bodily injury cases will be established within one working day from receipt of the initial report and clearly evidenced within the file.
• All claims will have a recorded statement from claimant as part of the file documentation.
• TPA'S basis for acceptance or denial of compensability will be clearly documented.
• Copies of all correspondence, including reports to the district's risk management division, or designee, and reports to excess carriers, will be documented in the file.
• All files should utilize a checklist. - Investigation and case management
• Prior to all initial payments of temporary income benefits, and unless a medical report has been received, the medical provider facility will be contacted to establish extent of injury, causal relationship to the alleged incident, and estimated return to work date.
• On all questionable cases, informative statements will be secured from the claimant, supervisor, witnesses, and any other pertinent parties, and the district's risk management division within three (3) working days of receipt of initial report, wherever possible.
• Medical reports will be obtained, or the medical provider contacted for same, as frequently as needed for verification of continuing indemnity payments.
• Initialed fax by the district will be obtained prior to each indemnity payment to confirm continued disability, provide status information, and discuss availability of modified duty and part time work.
• Telephone or personal contact will be maintained with temporarily disabled employees and their supervisor or other designated persons no less frequently than weekly, to maintain rapport and to monitor medical progress, return to work status and modified duties.
• Provide all reports which indicate reserve change analysis to monitor reserve practices.
• This analysis should indicate initial reserve, the reserve at closing and the final amount paid.
• Provide reports on loss development and forecasting reports which will allow the option for maintenance of a loss development file to project existing losses to ultimate reserve liability and to forecast inflation.
• Convert existing data from contractor or carrier to establish a database of historical claims, payments and reserves.
• Convert reports and data into a Microsoft excel format for further data manipulation and graphics.
• Timely recording of incidents with production of first report forms for submission to claim handler(s).
• Comprehensive underwriting, actuarial and loss forecasting statistics.
• Comprehensive safety analysis based upon the district’s recording of incidents.
- Contract Period/Term: 1 year
- Questions/Inquires Deadline: June 05, 2025