Third Party Administration Services

The Vendor is required to provide the transfer of data from the current workers’ compensation third party administrator (“TPA”).
- Claims Investigation and Management Philosophy
• Process all claims in accordance with the state workers’ compensation act.
• Provide the highest professional level of responsive claims handling, including regular on-going communication with injured employees.
• Advice injured employees of their workers’ compensation benefits in a timely fashion.
• Encourage early recovery from injury and early return to work in a light duty position.
• Keep open communication between TPA, the town’s risk manager, claimants, medical providers and attorneys.
• Pursue all possibilities of subrogation and second-injury fund recoveries. - Services include:
• On-line reporting claim ability as well as a toll free, 24 hours per day, seven days a week telephone number for town supervisors to report work related injuries or illnesses.
• On line claims portal to be accessed by the town for claim information, including adjuster notes, reserves, payments and loss runs.
• Assume all open claims existing at the beginning of the contract term and handle any re-opened claims and follow them through closure.
• Investigate and handle all newly reported claims.
• Contact the injured employee within 24 hours for a lost time claim and 48 hours for a medical only claim.
• Manage medical only claims to reduce the risk of becoming a lost time claim.
• Obtain and review all medical reports and bills related to the claim and establish if the fees charged are reasonable and customary.
• Establish and maintain a high-quality workers compensation managed care plan.
• Maintain accurate case reserves.
• Payments to claimants and providers will be made by the TPA on behalf of the town.
• All cash flow provisions will be mutually agreed to between the town and the administrator including weekly internal payroll vouchers.
• Report and monitor claims to the excess carrier in accordance with excess policy requirements.
• Meet with the risk manager and appropriate town personnel on an as needed basis and an annual meeting to discuss the status of open claims and other related risk management issues.
• Provide reports as needed.
• Maintain all closed files for a minimum of 10 years from the occurrence date.
• Such files shall be readily available to the town request.
• Determine any concurrent employment at the onset of a claim.
• Promptly notify the town’s risk manager of any settlement demands.
• With the approval of the town, arrange for qualified legal representation throughout all workers’ compensation proceedings.
• Nurse care management for catastrophic and non-catastrophic claims.
• Claims may not be settled without prior approval by the town’s risk manager and town’s finance director.
• This approval is subject to final approval by the town council at an executive session.
- A detailed case report by department showing all open claims with detail including status, claim number, name, loss description, occurrence date, paid-to-date, indemnity payments, medical payments, other (legal) fees and outstanding reserves (for each case).
- Contract Period/Term: 2 years