Third-Party Claim Administration Services

The vendor is required to provide that third-party claim administration services for its self-insured workers’ compensation program.
- Caseload, case review and documentation, claim creation, claim handling:
• Each claim file shall contain the examiner’s plan of action for the handling of that claim, including short and long-term goals and strategy. such plan of action shall be documented electronically.
• Consultant will investigate questionable claims with coordination, assistance and approval from the city.
- Communication: consultant shall:
• Respond to phone calls or emails to employees within one (1) business day.
• To all written correspondence, phone calls, and emails, from the city within one (1) business day.
• To all critical issues on the same day.
• Utilize emails, telephone, fax, scanning and written correspondence with treating physicians in order to secure written physical restrictions and/or limitations as a result of an industrial injury/illness.
• The consultant shall secure written releases for employees returning to modified or full duty in accordance with physician reporting responsibilities as specified by state and federal laws.
• The consultant has not received within two days after receiving report of an injury, the claims adjuster will contact the city to ensure was given to the employee within one working day of knowledge of the injury; form was not provided to the employee, the consultant shall immediately form to the injured worker.
• Make initial contact with claimant and establish claim file within 24 hours of receipt of the employers’ first report of injury from the city.
• Maintain regular contact with injured workers and their physicians with the goal of returning employees to modified or regular work as soon as possible.
• The physician’s office within one to three days after notice of a new claim and shall provide follow-up and intervention with medical service providers on behalf of the city and the injured employee.
• The point of contact for injured workers for assistance with all aspects of the workers’ compensation process, including the explanation of all entitled compensation benefits.
• All valid requests for reimbursement shall be paid to injured worker within thirty (30) days of receipt.
• Meet with and assist injured employees in resolving problems that arise from injury/illness claims as required.
• The city immediately upon receipt of an employee’s permanent work restrictions so that the city can determine the availability of alternate, modified, or regular work.
- Settlement:
• Consultant shall not approve, enter into, or authorize any settlement, including, but not limited to a stipulated award for permanent disability, or compromise and release for permanent disability, and future medical, without the prior written concurrence of the city.
• Settlement proposals directed to the city shall be forwarded by the consultant or defense counsel, in writing, along with a reasoned settlement recommendation accompanied by supporting documentation required by the city.
• Settlement proposals shall be presented to the city in sufficient time to process the request and obtain settlement authorization from either the city or the city council, as required.
- Claim decisions: consultant shall:
• The city’s concurrence and authorization for all claim decisions.
• Provide an in-depth analysis of rationale for all recommended claim decisions.
• Provide advance notice and explanation of any recommended claim delays or denials at least seven working days prior to determination.
• Establish claim reserves and provide a continual review and update of reserves to reflect changes during the life of the claim.
• Future medical claims shall remain open for two years from the last payment of any benefit.
• The claim notes to include settlement information, future medical care outline, last date and type of treatment, name of excess carrier, excess carrier reporting level, and excess carrier reporting history.
- Litigation and investigation:
• The city must authorize all investigative and sub-rosa activities.
• Consultant and the city shall ensure that defense counsel provide a written analysis of each case at intervals specified by the city.
• The city shall be informed of any settlement offers received from the claimant or claimant’s legal representative.
• The city shall be informed of all hearings, conferences or trial dates set by the workers’ compensation appeals board. at the request of the city, the consultant will attend hearings at no charge to the city.
• Consultant will represent the city in all matters related to the set-up, investigation, adjustment, processing, negotiation and resolution of workers compensation claims against the city.
- Audit:
• Consultant must maintain organized and well-documented claim files for each reported loss, which shall be available for audit by the city or its assigned representative.
• Consultant must cooperate fully with, provide requested information to, and respond to recommendations and findings of the city audit and actuary consultants.
• The city reserves the right to conduct financial audits of the trust account to ensure the integrity of the account.
- Employee training:
• Consultant shall provide training to the city personnel involved in the administration of the city’s workers’ compensation program.
• Consultant personnel shall be made available to the city on an “as needed” basis to provide city-wide supervisory and employee training on topics of interest to be determined by the city pertaining to the workers’ compensation program at designated city locations.
- Penalties:
• Consultant shall provide its services in a timely manner and in compliance with statutory requirements.
• All fines, citations, penalties or other assessments assessed because of a failure to comply with statutory laws and/or administrative regulations shall be the sole responsibility of the consultant.
• Consultant will reimburse the city within 30 days for any fines, citations, penalties or other assessments assessed against the city, unless the city agrees that noncompliance was not the responsibility of the consultant.
• Consultant shall provide a detailed monthly listing of all assessed fines, citations, penalties or other assessments, identifying the responsible party.
• Consultant’s responsibility for fines, citations, penalties and other assessments shall survive the expiration or early termination of the agreement.
- Database management services:
• Consultant must maintain accurate and timely loss runs, in a format and system acceptable to the city, and establish adequate reserves and post indemnity, medical supplemental job displacement benefits and loss adjustment expenses.
• Consultant must provide monthly loss runs to the city showing open and closed claim summaries by department.
• Consultant must provide monthly loss runs of all pending claims, which shall include: (1) a report of all claims by current fiscal year by department; (2) the current month new claims and closed claims; (3) all claims by date of injury by fiscal year; (4) all claims by payment type; and (5) all active claims in alphabetical order by department.
• Claim information shall include employee’s name, number, position, organization code, facility location, brief description of injury, location of injury and paid and reserve amounts.
• these reports shall be customized in a manner acceptable to the city.
• Consultant must provide online access to claim files and claim reporting capability. such access shall be provided for a minimum of two (2) city users.
• Consultant’s system shall have the capability to separately track lost time, days of modified duty assignments and temporary partial disability.
• Consultant’s system shall have the capability to record actual temporary and permanent disability indemnity exposure, listed separately for reserve purposes.
• Provide an annual loss run of all (open and closed) city claims.
• Consultant or the city may propose additional tasks as deemed necessary to complete the assignment. any additional work shall be negotiated and ordered through the issuance of an approved task order.
- Consultant deliverables include but are not limited to:
• Workers’ compensation claim administration services pursuant to state labor code.
• Monthly, quarterly, semi-annual and annual computer runs and reports.
• Quarterly management reports.
• Annual report of findings following a review of open cases and reserves to be submitted to the city prior to April 1st of each year.
• Statistical data for the self-insured annual report to be submitted to the city prior to September 1st of each year.
• Written file review, including recommendations for handling case to its conclusion if the case remains open after six months.
• Medicare reporting pursuant to agency
• Provision of appropriate claims forms, employer’s report forms and posting notices.
• Weekly report of temporary disability payments provided to the finance department.
• Daily check registers provided to the finance department.
- Questions/Inquires Deadline: February 07, 2025