Worker’s Compensation Third-Party Administrator Services

The vendor is required to provide for workers’ compensation claims handling services, payment services and other related services for its self-insured workers’ compensation program.
- Employ local city adjuster to adjust and manage workers’ compensation insurance (WCI) claims in accordance with established city policy and applicable state workers’ compensation act and rules;
- Complete and document three/four-point contact for each claim (employee, supervisor, provider and witness), if applicable, within 24 hours of receipt of the claim;
- Make and document daily attempts (unsuccessful and successful) to complete recorded statement as soon as possible to finalize the claim investigation and make the appropriate compensability determination;
- Manage a reasonable claim file work load per dedicated adjuster;
- Receive approval from the city prior to denying any claim and notify injured employee of denial prior to sending;
- Complete claim investigation and promptly file claim determination (acceptance, dispute or denial) as soon as appropriate;
- Obtain approval from the city prior to assigning outside vendors on any claim; requesting services could include, but are not limited to peer review, required medical exam (RME),
- Private investigation and case management services where necessary to maintain cost control;
- Identify and take necessary steps to report potential fraud;
- Upon approval from the city, utilize surveillance, where length or extent of temporary disability is questioned; outside investigation services, such as a private investigator, will be employed only where necessary; documentation of assignment will include specific reasons for referral; direction and control will be exercised over the investigator’s activities by the contractor with approval from the city’s risk manager;
- Ensure personal delivery of any documentation needed in order for any RME or designated doctor exam to be completed, at no additional cost;
- Timely delivery of medical/indemnity benefits, in accordance with state workers’ compensation act and rules to maintain 100 points compliance;
- Analyze medical documents and correspondence promptly upon receipt and take appropriate action based on the analysis and its effect on the claim;
- Provide the City with appearance hours as needed at no additional charge to address issues associated with claims handling activity or other aspects of the related services in the contract;
- Conduct claim review meetings as needed;
- Provide a monthly litigated claim report;
- Maintain accurate reserves and provide reserve reports to the City upon request;
- Cooperate and coordinate activities with vendors for all claims handling activities.
- Contract Period/Term: 1 year