Claims Administration Services

The vendor is required to provide claims administration service providers to administer self-insured workers' compensation claims and general municipal law 207-c administration services.
- For the year 2023, the county had 51 claims reported (4 claims with days away from work, 35 medical only recordable cases, and 12 reported for informational purposes). 
- For the year 2024, the county had 28 claims reported (6 with days away from work, 21 medical only recordable cases and 1 reported for informational purposes).
- Requirements:
1. Dedicated supervisor with no case load
•    The county requires a dedicated supervisor who is fully focused on overseeing the management of workers’ compensation cases without carrying a personal caseload. 
•    This role should provide direct oversight, facilitate communication, and ensure compliance and quality standards across all cases. 
•    The county reserves the right to require the vendor to replace members of the client service team, including claim adjusters and supervisors, as well as outside counsel and investigators, if, in the opinion of the county, the member(s) is not rendering the quality of service and cooperation required.
2. Dedicated call center in the country
•    To ensure responsiveness and high-quality customer service, the county expects a dedicated call center located with the country. 
•    This call center should be staffed with trained professionals familiar with our program and able to promptly address inquiries from employees and stakeholders.
3. Risk control services
•    Access to an online web service platform
•    A video library with relevant training materials
•    Free training sessions or courses
•    Collaboration or affiliation with safety institutions
4. Capability to understand and manage self-insured clients
•    Given the complexities of managing self-insured clients, the county requires demonstrated expertise and a proven track record in effectively managing such accounts including compliance, claims administration and reporting.
5. Current system upgrade and proof of system functionality
•    Provide detailed information about recent or planned upgrades to your claims management or related systems. 
•    Provide evidence of system capabilities and functionality. 
•    Real-time demonstrations to verify functionality and ease of use may be requested during the evaluation process.
6. Claims administration
•    Receive, examine and evaluate all claims, including workers’ compensation lost time claims (medical and indemnity) made by county employees of industrial injury, sickness, death and occupational disease; and determine the compensability thereof. 
•    Create a claim file for each reported loss or injury. 
•    Create a case history summary for all cases. 
•    Said case history should include the following:
o    Date claim filed;
o    Dates of any workers’ compensation hearings or other legal proceedings;
o    Name of attorneys representing the county at the legal proceeding;
o    Dates of investigations or medical examination;
o    Recommendations on how to proceed with case.
•    Institute an investigation of any reported claim or loss to the extent requested by the county, including the use of private investigators for surveillance. 
•    Perform all required administrative and clerical functions in connection with any claim, including but not limited to:
o    Conducting of any subrogation recovery, apportionment or contribution action which may inure to the benefit of the county. 
o    To engage medical consultants for the evaluation of any employee’s disability and need for treatment. 
o    To engage counsel for appearances in proceedings held by the workers’ compensation board to settle any claims loss or legal proceedings arising therefrom within the limits of the authority granted by the county, but not without prior approval by the county.
o    To communicate with the excess loss carrier immediately upon identification of all potentially serious cases, as well as those cases that threaten self-insured retention as indicated in the excess loss policy. 
o    To engage professional investigative services when determined to be appropriate by the county.
•    Provide and submit all forms, reports, and informational data necessary or mandated by law for the operation of the self-insurer’s program. 
•    this would include, but not be limited to, HCRA requirements, medicare secondary payer reporting, osha reports, dosh reports, second injury fund reimbursements, public goods pools, etc. 
•    Prepare management and claim loss reports of the status of pending claims, setting forth the file number, name of claimant, date of claim, nature of claim and anticipated liability with sufficient statistical and accounting data to permit the county to evaluate the program. 
•    These reports will be provided on a monthly basis, or as needed by the county. 
•    Case notes of a file shall include, but not be limited to the following:
o    Inform the county that a claimant is alleging amended, related or resulting injuries as a consequence of a reported injury, including recommended actions regarding same, i.e. psychiatric disability as a result of physical injury. 
o    Inform the county prior to each hearing evaluating issues and setting forth strategy to be followed at the hearing.
o    Report within fourteen (14) business days following each hearing synopsizing issues raised and decisions and orders rendered at the hearing unless a prior c-8 form is forwarded.
•    Prepare a voucher and transmit same to the county in sufficient time to avoid any statutory penalties for all medical compensation payments and awards required by statute to be paid. 
•    In order to aid the county in determining if a benefit should be paid, the awarded vendor will provide the county with a form that the county can quickly and easily determine the following:
o    The period of payment;
o    The number of days the payment is due;
o    The daily rate of payment;
o    The payment of any attorney’s fees;
o    Whether there is any reimbursement due to the county.
•    Must include a fraud endorsement statement on every payment issued for indemnity. 
•    Counsel engaged by vendor will be required to consult with the county attorney or her designee on all matters relating to contested claims, including but not limited to strategy, experts, and coordination of witness preparation and testimony. 
•    Counsel will be required to copy county attorney, or her designee, on all pre-trial correspondence and strategy material and submit a post hearing report on all claims.

- Contract Period/Term: 2 years
- Questions/Inquires Deadline: October 8, 2025