Workers Compensation and Claims Administration Services

The Vendor is required to provide the third party administrator hereinafter referred to as the “contractor” shall be assigned claims by the county.
- Services include:
•    Provide supervisory, administrative and adjustment services on claims as defined in this proposal, including advising the county with regard to actions, procedures, etc. That could result in controlling claims.
•    Shall provide dedicated claims and/service team for both workers’ compensation and state 207c claims.
•    Shall provide a special investigate unit (SIU) dedicated to the investigation and pursuit of fraudulent claims.
•    Have the capability to successfully develop and administer an effective ‘modified duty’/ return to work program.
•    Shall have a medical cost containment program and access to proven PPOS, PBM and pharmacy networks
•    Place all appropriate carriers on notice of loss and conduct necessary investigations as requested by the carrier.
•    The third party administrator must comply with the excess carrier’s conditions with regarding to reporting claims.
•    Must have a fully imaged claim system with client access to view all log notes, documents and claim activity.
•    Maintain all files and records necessary for defense of claims and/or other litigation or proceeding (such as actions for subrogation). 
•    Aggressively pursue all possibilities of subrogation, and/or recovery on behalf of the county.
•    Have the ability to provide regular data feeds to the self-insured’s excess insurer that includes encounter data (physician billing coding, prescription information etc.) As a critical piece of predictive analytic models.
•    Maintain status reports on all pending claims and provide summary reports for loss, in an accurate and timely manner that will be approved by the county.
•    Develop procedures and reports as required by the county on hard copy and database.
•    Provide a toll free number for plan members and claimants to use.
•    Have the ability to produce and mail checks, and submit a check register on a weekly basis that will be sent to the county for an electronic fund transfer.
•    Processing of medical bills and processing of payments to employees who are out of work.
- Claims Services
•    Accept reports of claims through email, internet or regular mail, as directed by the committee.
•    Initiate 3-point contact with claimant, claimant’s supervisor and treating physician(s) within 24 hours of receipt of claim notice.
•    Examine all claims submitted and create and maintain a complete file on each, including the setting of reserves or total estimated cost of the claim by expense area.
•    Conduct routine investigation and take appropriate measures to assure claim validity.
•    Review all claims to determine if additional investigations, such as surveillances, are necessary, assign and supervise that investigation and/or surveillance.
•    Conduct ‘special investigation’ as indicated by suspicious or potentially fraudulent claims. 
•    Assist and cooperate with external agencies on the reporting and pursuit of remedy as appropriate.
•    Monitor the treatment programs recommended for claimants by the treating physicians, specialists and health care providers for appropriateness and compliance by reviewing all reports prepared by them and maintaining such contact with these providers as may be appropriate.
•    Take all steps necessary for the control of claims, including assignment of, coordination with and review of the efforts of medical / disability case management services.
•    Recommend and facilitate the availability of managed care partners, including but not limited to, MRI facilities committed to examining claimants within 72 hours of authorization.
•    Schedule independent medical exams as necessary.
•    Prepare and submit in a timely manner all forms, reports, filings and payments mandated by the state or other governmental agencies to which the plan may be subject.
•    Maintain electronic agency reporting logs and assist with reporting requirements.
•    Segment and maintain electronic records of wc claims that develop into workplace violence cases, and assist with electronic reporting requirements.
•    Recommend benefits if any that should be paid to claimant.
•    Properly review, audit and prepare checks for payment in a timely manner for medical, indemnity, loss use awards and miscellaneous expenses related to claims.
•    Make available to the committee's representative's copies of all pertinent medical, legal and investigative reports, as requested.
•    Provide for appropriate notification to excess insurers as required by excess insurance policies.
•    Prepare and submit appropriate section iii medicare reporting required.
•    Pursue all subrogation and other recovery opportunities.
•    Prepare files in a timely manner for hearings and legal defense, and arrange for representation at all workers' compensation board hearings.
•    Utilize best practices and judgment in settling and denying claims and in setting claim reserves.
•    Advise the committee concerning opportunities to reduce the frequency and severity of work-related injuries.
•    Assist the committee with budgetary projections of the cost of the program.
•    Comply with all applicable laws and regulations regarding the administration of workers' compensation benefits.
•    Participate in the coordination, control and global settlement process of 207c cases.
•    Take over the management of all open claims from the current contractor.

- Contract Period/Term: 5 years
- Pre-Proposal Meeting Date: August 14, 2025
- Questions/Inquires Deadline: August 27, 2025