Third Party Claims Administration Cost Containment and Network Program Services

The vendor is required to provide third party claims administration (TPA) cost containment and network program services for claims administration and risk management services for self-funded workers’ compensation and liability programs.
- General administrative requirements
•    Maintain or establish, prior to the start of the executed contract, an office located in state with a state-based account manager, a dedicated workers’ compensation and liability supervisor, and sufficient dedicated claims staff to handle the county’s account as contemplated under both this RFP and applicable contract. 
•    Ensure the maximum caseload by each licensed adjuster will be no more than each of the following:
o    Workers’ compensation: lost time – 100 claims 
o    Workers’ compensation: medical only – 225 claims
o    Liability – 150 occurrences
•    All adjusters designated for the county account, which is covered by the executed contract, must maintain a valid and appropriate state adjuster license related to their business area of insurance. 
•    Provide electronic capability to report claims covered by the executed contract directly into the applicable claims system to the county and its designated risk management personnel have access.
o    Option to have and maintain a web-based RMIS reporting system to the county’s designated representative. 
o    County’s representative will have access and usage, at no additional cost, for entering both workers’ compensation and liability claims as well as other reported incidents. 
o    All claims submitted by phone or electronically during normal business hours must be entered into the selected TPA vendor(s) claims system by the selected TPA vendor(s) on the same business day. 
o    The county should have access to real time notes which are stored on the claims system in connection with all such claims and incidents.
•    The county elects to proceed with a workers’ compensation network, the TPA vendor will support its transition and utilize it for all the county’s existing and future WC claims. 
•    Meet with the county’s designated risk management staff, as well as the county’s then current and designated insurance consultant, on a monthly basis or as needed when determined necessary by the county, to discuss the status of active files, claims handling concerns, program operational issues and other areas of concern which are covered by the services to be performed under the terms and executed contract.
o    Make all loss reports available to the county’s designated representative and insurance consultant in an excel format for the purpose of marketing coverage on the county’s behalf. 
o    Provide periodic information to, and cooperate with, the county’s actuarial service provider.
•    Keep the county fully apprised of significant changes in the state of workers’ compensation rules and tort law that may affect the county as soon as changes are known. 
•    Comply with all applicable rules and regulations promulgated by the state commissioner of worker’s compensation.
•    Provide notices for continuing education courses offered in (sixty (60) days or as soon as practical) which the county’s designated risk management personnel either may be interested in or required to attend. 
•    Assume the role and responsibilities of the county’s reporting agent with respect to workers’ compensation and liability claims as well as other required reported incidents, pursuant to act 2007, as amended from time to time throughout the term of the executed contract.
o    Prepare and submit all queries and quarterly reports with respect to both workers’ compensation and liability claims, as well as other required reported incidents to the center for medicare and Medicaid services (CMS) in accordance with act. 
o    Indemnify, defend (upon the county’s written request) and hold county harmless from and against all fines and penalties levied against the selected TPA vendor(s) or county for the selected TPA vendor(s) failure to comply with any applicable act requirements. 
o    TPA vendor(s) pass along or otherwise cause the county to pay fines, which levied solely against the selected TPA vendor(s) or levied against the county due to the selected TPA vendor(s) negligence, error or omission.
•    Include a complete and accurate description of the current policies and procedures of the TPA vendor to ensure and measure internal quality control of all duties and responsibilities required of the TPA vendor in connections with the executed contract.
- General claims processing
•    Perform such functions normally contemplated to be the function of TPAs including, but not limited to, assuming responsibility for the management of pending, new and reopened claims. 
•    Investigate, adjust and subrogate all reported claims in accordance with the applicable provisions of the state workers’ compensation act and state tort claims act, as well as any applicable ordinances, as each may be amended from time to time throughout the term of the contract, unless otherwise directed by the county’s designated risk management representative. 
•    Report all workers’ compensation and liability injury cases to the central index bureau (CIB) upon file creation, at its vendor’s sole cost and expense, with a complete and accurate copy of all case information retained in the electronic file. resubmit an index electronically to the CIB every six (6) months until the applicable case is closed. 
•    The selected TPA vendor will not allocate any applicable CIB expense to the county. 
•    The selected TPA vendor(s) management and supervisory level personnel will assign claims, utilizing appropriate cost center numbers, as provided by the county, to appropriately reflect originating department. 
•    Use a thirty (30) day adjuster diary system for timely file review of each claim file being handled or managed on the county’s behalf under the terms of any executed contract. 
•    Each file diary review including reserves, must be documented, in detail, in the applicable computer file notes. 
•    All claim reserves will be monitored and adjusted accordingly. 
•    File notes must contain an explanation for any adjustment. 
•    Estimate, establish and maintain claim reserves on a “most probable” basis. 
•    Claim reserving practices, for each claim file, the selected TPA vendor(s) must take into consideration the indemnity, medical, rehabilitation and allocated expense categories, and all other major sub-categories of each.
o    Changes in claim reserves must be reviewed and approved by the selected TPA vendor(s) designated claims supervisor. 
o    Any claims reserve contemplated over $25,000 requires either written or digital notification to, or either written or digital consent by or from the county’s risk management and compliance director or their designee.
- Workers’ compensation claim processing
•    Establish and assign WC claim files within one (1) business day from receipt of the initial report submitted by the county. 
•    Increase productivity, efficiency and quality with respect to the WC claim files submitted by the county, while reducing claim expenses to improve overall claim outcome. 
•    Review of WC claim files management, determination, treatment plans, medical codes, and preparation and submittal of written or digital summary of findings to the county’s risk management and compliance director or their designee. 
•    Contact each applicable lost time injured employee, WC network medical service provider and county department associated with the lost time injured employee within twenty-four (24) hours of claim assignment by the county.
o    Contact to the lost time injured employee shall be by means of telephone call, email or mailed contact letter.
o    The department head of the affected county department associated with the lost time injured employee must be notified if the lost time injured employee cannot be reached by means of telephone call.
•    Obtain lost time injured employee’s signature authorizing the release of their medical records. 
o    Obtain copies of all medical bills and records associated with such employee.
•    Provide a written summary of the injured employee’s injuries to the independent medical exam doctor, required medical exam doctor and designated doctor, along with copies of all medical reports and films necessary for a successful and complete examination. 
•    Take and retain complete and accurate copies of recorded statements from all lost time injured employees as part of any WC related investigation. 
•    Maintain personal contact with injured workers who have active lost time claims a least once every two (2) weeks in order to maintain rapport and monitor medical progress and overall status. 
•    Notify the injured county employee in writing when impairment benefits are owed.
o    TPA vendor(s) must issue the first lost time check to the injured county employee and explain all the benefits owed to the employee, including any applicable medical benefits.
•    Have the capacity to issue income benefits electronically via direct deposit to any injured county employee, as directed by the county. 
•    Provide injured county employees with electronic access to their claim file, claim payment status and pending health care appointments for all device platforms, including smart phones. 
•    Create or maintain a customer satisfaction survey mechanism for the county employees and provide findings to county judge or risk management and compliance director (or their designee) as directed on a quarterly basis.
•    Obtain written or digital approval from the county risk management and compliance director or their designee on surveillance, case management referral, peer review and vocational evaluation. 
•    Pursue all applicable contributions for recovery potential from responsible party or parties.
- Liability claims processing
•    Initiate claims investigation with claimant(s), witnesses, affected county personnel, and any other necessary parties within one (1) business day after the receipt of a claim by telephone or in person by the selected TPA vendor(s). 
•    Attempt to take recorded statements from all liability claimants as part of investigation.
o    TPA vendor(s) must include a note in file if liability claimant refuses to provide a recorded statement and an explanation for the refusal.
•    Secure photographs of the location in question on all liability claims involving the condition of tangible personal or real property, when appropriate. 
•    Assign an appraiser to inspect all property damage claims, where appropriate.
o    Each inspection must include an itemized description and photographs of the damages.
•    Create, implement, and maintain a system to code and track all liability losses and claims covered by an executed contract by the following line of businesses.
o    Commercial general liability
o    Auto liability
o    Employment practices liability
o    Public officials
o    Law enforcement liability
•    Secure and review copies of all applicable third-party contracts for any affected insurance and indemnification requirements, where appropriate. 
•    Tender claims to third party contractor or other entities, where appropriate. 
•    In litigated cases, coordinate contact with office – civil division through the county’s risk management department. 
•    Deny a claim if the selected TPA vendor(s) determine(s) that the county has no liability or where immunity has not been waived; provided however, the county reserves the right to make such determinations on its own. 
•    Make recommendations promptly (either digitally or in writing) to the county’s risk management department regarding investigation, negligence, and potential liability in connection with each liability claim handled under this section. 
•    Negotiate settlement of the liability claim if either the selected TPA vendor(s) or the county determines liability exists and immunity has been waived. 
•    Make payments promptly on all approved settlements.
- Risk management information system
•    Electronic reporting to the proper authorities of all claims required by act is mandatory. 
•    The selected TPA vendor(s) must provide all the software applications (claim platform) which are necessary to perform the services and provide the deliverables required under this section and the applicable provisions of the executed contract.
o    TPA vendor(s) must identify and proceed to correct, patch or replace any inoperative software within forty-eight (48) hours after the county reports a problem.
•    TPA vendor(s) must provide the county with direct access to its RMIS for as many users as the county requires, for the term of the executed contract, including any renewals or extensions, plus an additional thirty (30) days after the executed contract expires or is terminated at no additional cost to the county.
o    Risk management department must have direct access to the RMIS electronic claims file and report writer, and have the ability to enter notes, diaries, attachments and review all notes in real time.
•    TPA vendor(s) risk management information system (RMIS) must be capable of, though not limited to, performing or providing each of the following.
o    Secure county data. 
o    Provide county’s designated users with access to all such secured county data, via standard internet connection, 24 hours a day and 7 days a week throughout the term of the executed contract. 
o    Direct claim reporting of new claims 24 hours a day and 7 days a week. 
o    Collect and store all usual and necessary statistical claim information data for the county. 
o    Capture detailed information on: medical bills, other payments, the county, injured county worker, insured county worker history, workers’ compensation (WC) network service provider, diagnosis and treatment. 
o    Report the number of claims for a specific time period by injury date and by report date for each claimant. 
o    Accurately calculate the number of full and partial days of disability for each claim, accounting for all periods of intermittent changes in the claimant’s work status; accounting for all periods of intermittent changes in the claimant’s work status. 
o    Produce monthly reports to the county’s risk management and compliance director (or their designee) on all injured county employees who, in addition to the claim filed in a particular month, have filed one or more prior claims with the county. 
o    Accurately reflect and report to the county’s risk management and compliance director (or their designee), upon request, paid and incurred amounts of net subrogation recoveries associated with each claimant.

- Contract Period/Term: 3 years
- Questions/Inquires Deadline: September 19, 2025