Third Party Administrator Services

The vendor is required to provide third-party administrators (TPA) to provide workers’ compensation claims administration for authority self-insured workers’ compensation program.
- The TPA will assist authority risk management unit in administering and maintaining a comprehensive and cost-effective workers’ compensation program.
- Program administrative services – responsibility of the TPA
•    Staffing requirements
o    Claims unit supervisor shall have a valid state of self- insurance certificate and shall have not less than six (6) years’ experiences in public entity workers’ compensation self-administration claims handling, or equivalent experience acceptable to authority.
o    Senior claims examiner shall have a valid state of self-insurance certificate and shall have not less than four (4) years’ experiences in claims adjusting with not less than one (1) year experience with public entities.
o    Claims assistant shall have not less than one (1) year experience in workers’ compensation claims, including “medical only” claims.
o    Medical only clerk shall have not less than one (1) year experience in workers’ compensation medical only claims
o    Authority should have final approval of all claim’s personnel dedicated to their account.
•    The TPA shall meet all legal requirements of the state, including but not limited to the rules and regulations for self-insured and the state administrative code.
•    Provide ongoing communication with the injured employee, medical providers, and authority on the status of claims, providing advice on how to manage injured workers and offering support for employees navigating the workers’ compensation system.
•    Provide authority with information on changes, or proposed changes, in statutes, rules, and regulations affecting authority responsibility under a self-insured workers’ compensation program.
•    Compensation program progress, including problem areas with recommended solutions for claim handling, electronic system enhancements, including any future enhancements, if applicable, and an evaluation of the electronic communication between both parties either as needed and quarterly in conjunction with the claims.
•    Provide “facts for injured workers” booklets and employee pamphlets written in Spanish and English, which delineate the benefits and rights of injured employees and make available electronically.
•    Provide and maintain a 1-800 reporting number for authority staff members’ use in communicating with the TPA.
•    Help to minimize the overall cost of workers’ compensation program which includes but is not limited to negotiating medical treatment costs, advocating for cost-effective rehabilitation services, and identifying fraudulent or unnecessary claims.
•    Provide connection and access to an online database system or platform to report new claims and access TPA claim files at no additional charge to authority.
•    Provide at the TPA’s expense, dwc-1’s and medical authorization forms to authority electronically with user-friendly accessibility.
•    Provide comprehensive, full-captioned reports identifying the status of the plan of action in a format acceptable to authority on an annual basis in writing for all pending, litigated or large loss claims (cases which exceed or are likely to exceed $50,000 in permanent disability payouts).
•    TPA shall assist with updating safety-related policies and procedures to comply with any new or amended regulations related to safety.
- Claims administration services
•    Maintain a claim file on each reported claim. investigate, review, adjust, and otherwise administer claims (including the arrangement of sub rosa investigations), or retention of hearing representatives, in–house counsel or defense counsel for litigated claims in accordance with statutes, rules and regulations governing the administration of workers’ compensation claims.
•    Contact all employees whose claims are non-litigated and which involve lost time (three or more days or with potential permanent disability) by telephone within forty-eight (48) hours after the claim is reported to the TPA.
•    Notify authority, within 48 hours of knowledge or as soon as practical, when the employee has permanent work restrictions and limitations that have caused permanent disability (pd) for purposes of engaging in the “interactive process” in accordance with the fair employment housing act (FEHA)
•    Investigate the circumstances surrounding each claim to ensure that the injury or illness is work-related and that it meets the criteria for workers’ compensation.
•    TPA with existing special investigative resources to investigate all suspicious claims.
•    Determine compensability of claims in accordance with statutes, rules, and regulations governing the administration of workers’ compensation claims and in accordance with state labor code.
•    Determine eligibility for and recommend payment of medical benefits, and authorize routine medical examinations in a timely manner to determine the nature and extent of disability, when appropriate.
•    Review, compute, and recommend payment of temporary disability, permanent disability, and supplemental job displacement benefits due an injured employee in a timely manner, whether paid voluntarily or under decisions, orders, or findings and awards.
•    Pay claims and allocated loss expense payments from the trust account established by the TPA and authority.
•    TPA shall immediately (within one business day) notify authority verbally and in writing when funds in the trust interest account are likely to drop below $150,000, or prior to issuing the payment.
•    TPA shall not draw on the trust account for any purpose other than payment of claims and allocated loss expenses.
•    TPA shall submit to authority excess carriers, claims for reimbursement within thirty (30) days of exceeding the self-insured retention (sir) and every 90 days or less thereafter, for all current and new claims in the form prescribed by the excess carrier with a copy to authority.
•    TPA shall cooperate, coordinate, and report all claims in a timely manner to authority excess carrier in accordance with the applicable excess policy.
- Medical management services
•    Recommend and maintain a panel of physicians, dentists, chiropractors, and other practitioners, including preferred provider organizations for initial treatment of injured employees and recommend a panel of such specialists as may be required for long-term or other disabilities requiring special treatment.
•    Monitor and confirm treatment programs for injured employees, including review of all “doctor’s first report of work injury”, to assure that treatment is related to compensable injury or illness.
•    Audit and pay all medical expenses in accordance with the fee schedule as adopted by the department of industrial relations, division of workers’ compensation.
•    Should a hospital bill require outside independent audit, the cost shall be paid out of the claims file under the allocated expense category. 
•    Maintain close liaison with treating physicians and other medical providers to ensure our employees receive proper medical treatment and to avoid “over treatment” situations.
•    Consult with appropriate authority personnel and provide guidance and evaluations of the physical capabilities of injured employees, including those cases where injury residual might involve work restrictions.
•    Provide, on an as-needed basis, medical management and utilization review services with company (IES) which are acceptable and approved by authority.
•    Complete administration and processing of all lifetime medical cases awarded or ordered by the workers’ compensation appeals board during the term of this agreement.
- Budget exceeds $1 billion.

- Contract Period/Term: 1 year
- Questions/Inquires Deadline: August 6, 2025