Third Party Administrative Services

The vendor is required to provide that third party administrative services for workers compensation and long-term disability.
- Claims administration services:
• The obligations of claims management and administration under the workers’ compensation laws, applicable case law and administrative regulations, and in addition shall provide the reports and perform the related work described herein.
• Must assign dedicated adjusters with expertise equal to or exceeding the level needed on any given claim and a case load at or below 125 active indemnity claims.
• All files on a stated periodic basis with evidence of such action in the claim files. in addition, there will be evidence of a supervisory review of all files being transferred to legal counsel for hearings.
• The ability to independently select vendors of choice for medical case management, diagnostics, surveillance and other claims related services.
• A maintain computerized data base with online access available to district personnel and contracted consultants as approved by the district.
• The successful over all open cases from the preceding workers’ compensation claims administrator and integrate them into their claims management system/database.
• The successful also enter into this computerized data base system all individual expenditures to date available from the quarterly and final reports issued by prior administrator.
• It is expected that all data in the existing computer database will be transferred to any new potential database.
• The be available for consultation upon reasonable notice for claims meetings to identify and analyze all workers’ compensation claims, make recommendations for corrective action, implement the corrective action, and monitor the results as agreed in the monthly claims meeting.
• All forms including, but not limited to, incident reports, c-2f, c-11 and c-240 forms submitted by the district and will generate the appropriate FROI, SROI and/or other electronic forms required by the workers’ compensation board in accordance with EDI and payor compliance specifications.
• determine for each reported injury those benefits, if any, that should be paid or rendered under the applicable workers’ compensation law
• Review claims within 48 hours of being reported by the district and follow up with appropriate level of investigation.
• Complete their investigations of newly report claims including their 3-pointcontacts within 48 hours
• Prompt payment of legitimate claims and aggressive pursuit of all issues related to controverted claims
• Establish and maintain realistic reserves based on the merits of the claim while utilizing the medical treatment guidelines, permanency/impairment guidelines and TPA best practices to mitigate and/or close claims in accordance with state WCB regulations.
• Develop losses at least annually to reflect IBNR factor acceptable to district auditors.
• discuss any claim issues with district risk management & compliance officer or designee to obtain any necessary file documentation.
• Provide clear and concise direction to defense counsel to ensure success in the management of litigated cases.
• Make recommendations for and assist with the prevention of workers’ compensation fraud.
• Arrange for surveillance and make recommendations regarding surveillance for the prevention of fraud and abuse when approved by the district.
• Responsible for pursuing and securing subrogation or contribution from other parties
• Office at least bi-annually to conduct claim reviews with district auditor and appropriate dept. heads/district personnel.
• The district and treating medical providers to determine alternate duty assignments when available and appropriate.
• The capability to query and report on a quarterly basis claim to the center for medicare services
• The workers’ compensation files, along with all computer data associated with them, is the property of the district.
• The event of termination of services between the contractor and the district, the contractor will perform an orderly and complete transfer of all paper and computer data to the satisfaction of the district
• Obligate itself to provide information necessary for continuous claims handing after the expiration of a subsequently successful
- administrative:
• The district risk management & compliance officer in annual preparation of plan budgets as requested.
• The district in responding to inquiries arising during financial audits or inquiries from other government agencies.
• The district of significant changes in statutes or case law
- Contract Period/Term: 1 year
- Questions/Inquires Deadline: February 28, 2025