Workers’ Compensation Claims Administration Services

The vendor is required to provide that workers’ compensation third-party claim administrative services, including medical provider network management and bill review.

- The TPA will prepare an individual claim file based on PRISM guidelines. The claim file shall be available to City representatives, claims auditors, and agents for inspection, and contain all medical and factual information on each claim reported.

- TPA, at the discretion of the City, will provide on-site claim file reviews on a quarterly and annual basis. Other periodic on-site or virtual claim file reviews will be scheduled based upon the needs of the City. On-site claim file reviews are preferred. The TPA will provide claim file review packet at least one week in advance of the schedule claim files review meeting. The TPA is expected to send claims staff and supervisory personnel to attend claim file reviews at no charge to the City

- TPA shall first obtain authority from the respective City’s to delay or deny a claim. The City’s authorization shall be clearly documented in the applicable claim file or in the computer system

- TPA agrees to provide un-redacted medical reports as requested by the City to enable the City to determine limitations, restrictions or permanent work restrictions.

- TPA shall provide Medical Provider Network Management Services which may include but are not limited to the following:

• A Medical Provider Network (MPN), which meets the State Laws and Regulations and the Workers’ Compensation Administrative Director requirements, per Labor Code 4616, and the needs of the City. The needs of the City include at least two public safety specific mental health providers. If the City implements an MPN, the TPA is expected to maintain the MPN. Management of the MPN includes the dispute of medical treatment processes, as well as MPN correspondence regarding transfer of care as required.

• Provide necessary documents to the City so that the City can fulfil the requirements of notification to their employees.

• In the event an MPN modification is filed, the TPA will submit, on behalf of the City, the plan to the Workers’ Compensation Administrative Director. The TPA will also act as the Division Liaison to the Workers’ Compensation Administrative Director to ensure compliance with the modification plan approval process.

• The TPA will provide an updated MPN listing to the City upon update.

• The TPA and City will meet annually, at the end of the fiscal year, to review MPN program.

- Contract Period: 1year