Workers Compensation Third Party Administrator and Managed Care Program Services

The vendor is required to provide workers compensation third party administrator (TPA) and managed care program services for risk management and county counsel as required.
a. Claims administration
•    TPA must adhere to the current prism claims administration standards at all times while administering the county's self-insured workers' compensation program. 
•    Compliance with prism standards will be ascertained during the prism audit process.
•    Public risk innovation solutions management (PRISM) administration standards, the TPA is responsible for complying with all contractual and fiduciary obligations, the county's performance standards and regulations, and statutes governing workers' compensation and self-insurance programs, including case law.
b. Claims personnel
•    The TPA is responsible for providing sufficient and competent staffing to fulfill the contractual requirements. 
•    Current policies regarding the assignment of claims to each claim supervisor, claims examiner, and claims assistant.
•    Including specific information outlining experience in handling self-insured public agency claims, emphasizing recent experience handling claims for safety officers under labor code
•    Supervisors and managers must have a minimum of ten (10) years of experience handling and supervising workers' compensation and be sip certified at the time of the contract start date.
•    Staffing shall include at a minimum one supervisor, all required adjusters and senior examiners, all required adjuster and senior examiner assistants, and appropriate support staff.
•    TPA shall have four or more examiners assigned to the county at all times, unless a hybrid option is implemented.
•    A claims supervisor, claims manager, or vice-president of workers' compensation shall be available by telephone for emergencies through a 24-hour emergency telephone number.
•    TPA shall ensure that one or more examiners are on call and available to the county every business day throughout the contract period from the hours of 7:30 am to 5:30 pm PDT.
•    The event of an examiner vacancy or leave of absence for any reason, the county shall be immediately notified. 
•    The examiner's position shall be backfilled by another examiner within seven (7) working days.
•    TPA shall ensure each claims examiner handling the county's claims will receive continuing education each year.
c. Caseload, case review and documentation, claim creation, claim handling
•    The claims examiners assigned to the county shall handle a targeted caseload of between 130 to140 indemnity claims, not to exceed 150 indemnity claims per desk. 
•    It is expected that the TPA shall assign dedicated examiners to administer the county's workers' compensation program.
•    Each claim file shall contain the examiner's plan of action for the future handling of that claim, including short and long-term goals and strategy.
•    TPA will investigate questionable claims with coordination, assistance, and approval from the county.
d. Communication
•    TPA will respond to phone calls or emails to employees within one (1) full business day. 
•    All documentation will reflect these efforts.
•    TPA will respond to all written correspondence from the county within 48 hours of receipt.
•    TPA will notify the county within 48 hours of receiving any medical report or information regarding temporary or permanent employee work restrictions.
•    Upon knowledge of a catastrophic claim, the TPA shall immediately notify risk management team.
•    TPA will respond to all critical issues, employee complaints, and urgent notices with contact directly to risk management team on the same day.
•    TPA shall utilize telephone, fax, and written correspondence with treating physicians to secure written physical restrictions and limitations resulting from industrial injuries and written releases returning employees to modified or full duty in accordance with physician reporting responsibilities as specified within applicable state federal regulations.
•    The TPA has not received the state division of workers’ compensation workers’ compensation claim form (dwc-1) within two days after receiving the report of an injury, the examiner will contact the county to ensure that the dwc-1 form was given to the employee within one (1) business day of knowledge of the injury.
•    TPA shall make initial contact with the claimant and establish a claim file within one (1) business day of receipt of the employers' first report of injury from the county. 
•    TPA will explain department of workers' compensation benefit notices and other required letters and forms.
•    TPA shall maintain regular contact with injured workers and their physicians with the goal of returning employees to modified or regular work as soon as possible.
•    TPA is to contact the physician's office within one to three (3) business days of notice of all new claims and shall provide follow-up and intervention with medical service providers on behalf of the county and the injured employee. 
•    TPA shall obtain concurrence and authorization from the county for all wording included on form letters to be mailed to county employees. 
•    TPA shall be the point of contact for injured workers for assistance with all aspects of the workers' compensation process, including an explanation of permanent disability ratings, supplemental job displacement benefits, and other benefit notices. 
•    TPA shall determine the nature and extent of permanent disability and arrange for an informal disability rating whenever possible to avoid workers' compensation appeals board litigation. 
•    The TPA shall explain to the injured employee permanent disability ratings, assist the employee with completing the necessary forms, and send all permanent disability benefit notices to the employee as required by the state labor code. 
•    The TPA will meet with and assist injured employees in resolving problems that arise from injury or illness claims.
e. Claim decisions (delay, accept, reject, and compensability)
•    The compensability determination (accept claim, deny claim, or delay acceptance pending the results of additional investigation) and the reasons for such determination will be made and clearly documented in the claims system’s notes within five (5) working days of the receipt of the notification of the loss, as well as communicated to the county’s risk management team.
•    TPA will provide the county with an in-depth analysis of the rationale behind all recommended claim decisions.
•    TPA will provide advance notice and explanation of any recommended claim delays or denials at least seven (7) working days prior to the decision date.
•    The TPA shall notify the county of acceptance, delay, or denial of any claim.
•    TPA will establish claim reserves and provide a continual review and update of reserves to reflect changes during the life of the claim in accordance with prism claims administration standards.
•    Future medical claims shall remain open for two years from the last payment of any benefit.
•    Documented in the claim notes to include settlement information, future medical care outline, last date and type of treatment, name of the excess carrier, excess carrier reporting level, and excess carrier reporting history.

- Contract Period/Term: 3 years
- Questions/Inquires Deadline: September 15, 2025