Workers Compensation Third Party Claims Administrator Services

The Vendor is required to provide for a strong, long-term partnership for third-party workers’ compensation claims administration (TPA) services for the city’s self-insured workers’ compensation program.
- The City has been permissibly self-insured for workers’ compensation for over 30 years.
- The Risk Manager is responsible for contract administration and management, and works closely with the TPA and internal staff to ensure quality medical care, open communications and appropriate assistance with injured and ill City employees.
- The City’s self-insured retention is $500,000.
- These administrative services will be inclusive of, at minimum, an early return-to-work program and utilization review, nurse case management, and bill review.
- Claim File Set Up
•    Upon receipt of the employer’s report of occupational injury or illness or application for adjudication of claim, the TPA will prepare an individual claim file based on prism guidelines.
•    The claim file shall be available to the city, including their representatives, claims auditors and agents for inspection, and contain all medical, factual and reserve information on each claim reported. It shall contain, at minimum:
•    The examiner’s plan of action for the handling of that claim, including short and long-term goals and strategies. Such plans of action shall be documented electronically.
•    TPA will investigate questionable claims with coordination, assistance, and approval from the City.
- Customer Service
•    Two dedicated claims adjusters and claims supervisor shall be assigned to the city’s account along with appropriate support staff. With at least seven (7) years of supervisory experience of claims in the public sector, inclusive of labor code 4850 benefits and presumptive injuries. 
•    The city retains the right and opportunity to interview, approve, and/or reject all proposed individuals to be assigned to the city’s account.
•    TPA shall, at all times, have two or more claims adjusters assigned to the city. 
•    TPA shall ensure that two or more claims adjusters are on call and available to the city every business day throughout the contract period from the hours of 8:00 a.m. To 5:00 pm., Pacific Standard Time, Monday through Friday.
•    Utilize emails, telephone, fax, scanning and written correspondence with treating physicians in order to secure written physical restrictions and/or limitations as a result of an industrial injury/illness.
•    TPA shall provide city with quarterly reports of all complaints received, resolution and documentation of follow up with an employee. 
•    The report may be reviewed during the on-site claim reviews on a basis.
•    The city requires all claims examiners to have received the Office of Self-Insurance Plans certification.

- Contract Period/Term: 1 year
- Questions/Inquires Deadline: November 03, 2025