Professional Claims Administration Services

The vendor is required to provide a dedicated claims unit, whose sole responsibility is the administration of the authority’s workers’ compensation claims.
- The TPA shall designate a full-time, qualified claims account supervisor to manage the service agreement and act as the primary point of contact for the authority, as well as a team lead and will provide the requisite number of licensed adjusters. 
- Adjuster caseloads must not exceed standard statewide best practices by type of loss and complexity.
- Upon receipt of the first report of injury (FROI), the TPA shall begin the administration process with the establishment of a claims file that should include automatic completion, and statutory filing, of a new claim summary report with a copy sent to the authority including the assigned claim number. 
- All claim files, within the laws regarding medical information, are to be made available for review by the authority at any time during the TPA’S regular business hours.
- The authority must be notified immediately, via telephone and e-mail, of all newly reported catastrophic claims (threshold to be determined) upon receipt of the first notice of loss.
- All claims meeting the reporting requirements shall be reported electronically to the appropriate jurisdiction within the timeframes mandated by said jurisdiction.
- The adjusters will perform and provide: (i) three-point contact within 24 hours of report with the injured worker, employer and treating physician; obtain recorded statements of the injured worker (other civilians, witnesses, supervisors and doctors, as needed), all possible reports, photographs and diagrams of the scene, and use video when appropriate; (ii) in-depth claims investigations on all lost-time claims and are required to complete an initial investigation within seven (7) days from date of receipt of the claim, with all final lost-time investigations will include a compensability determination plan of action within 14 days of receipt of the claim, or earlier; (iii) third-party investigations; (iv) prior loss history and medical records; (v) diligent monitoring of lost time; (vi) indicate aggressive use of independent medical evaluations (IME)and functional capacity evaluations (FCE); (vii) offset, lien and credit analysis; and (viii) proper notification to excess carriers of potential claims in accordance with the terms of the carrier’s service agreement.
- Complete a thorough analysis of relevant factors to determine compensability and coordinate recommendations with the authority for settlement/disposition of claims. 
- Settlement evaluations will be made promptly based on coverage, liability, damages and available defenses and will be documented in the claim file. 
- Request reports from the index bureau upon request from the authority. 
- Final settlement authority shall rest with the authority. 
- Claim petitions must be forwarded to approve counsel promptly.
- All claim-related phone conversations, discussions, meetings, supervisory directives and action plans must be clearly detailed and documented in the claim file.
- All action plans must be comprehensive, list specific steps to bring each claim to closure as expeditiously as possible at the lowest possible cost and must be updated every 90 days or sooner as needed.
- Establish banking arrangements, in conjunction with the authority, to pay indemnity/medical/legal and other expenses incurred as well as benefit payments to which eligible employees are entitled.
- All payments to claimants, providers and vendors must be made promptly and within the statutory requirements. 
- Complete and submit payroll adjustments on lost time claims with salary continuation to the authority monthly. 
- All lost time claims require that 24-hour contact be made and documented to the injured employee, treating physician’s office, and employee’s supervisor.
- Must provide monthly reports broken down by facility, i.e. date of loss, accident description, injury description, lost time status, and accident state.
- Audit all hospital and medical provider charges for compliance with the fee schedule(s) or with usual and customary rates.
- TPA shall monitor medicare eligibility for individual claims and conduct conditional payment searches as mandated.
- Provide necessary notification to all excess carriers based on their specific reporting requirements for claims which threaten the self-insured retention levels and provide payment information on those claims which have exceeded the retention amounts and are eligible for payment.
- Electronic data management system must have the capability to transfer all claims data via electronic “system-to-system” feed to-and-from authority systems – including all files handled by in-house counsel. 
- Electronic claims files are required to be kept on a current diary system, with profiles for quarterly review of all open files.
- TPA shall provide secure, electronic reports to allow performance of certain routine data analysis by the authority (i.e., new claims, closed claims, paid losses, incurred costs, the progress of individual claims and the effectiveness of safety and other cost control programs, financial history and diary notes as compiled in the system).
- Provide properly documented policies and procedures (i.e., manual) related to claims administration and processing, including comprehensive management reporting (e.g., pending claims, closed claims, investigated claims, etc.), fraud prevention, internal audits and quality assurance programs.
- The authority must pre-approve via email the pursuit of any third-party action subrogation claim.
- The TPA shall engage with the port authority to review medical bills.
- Contract Period/Term: 3 years
- A Virtual Pre-Proposal Meeting Date: July 8, 2025
- Intent to Bid Due Date: July 21, 2025