The vendor required to provide comprehensive third-party administration (TPA) services for board worker’s compensation and general liability programs.
- Claims administration shall satisfy the following minimum requirements:
• Provide effective customer services for employees, guardian of student, or patrons seeking information regarding claim status, benefit determinations, and other relevant matters.
• Complete initial claim investigation within 5 days from receipt of the claim and if needed, complete further investigation within 10 days or as soon as all the facts of the case can be reasonably gathered.
• Investigations may be conducted telephonically or on-line unless an on-site investigation is warranted.
• For worker’s compensation, provide a compensability analysis following industry best practices, or 24-hour 3-point contact on all claims.
• Compensable claims will result in a thorough explanation of benefits letter and e-mail to the injured employee describing the investigation, benefits available and statute of limitations.
• When a file remains under review for investigation of compensability, a letter and e-mail will notify the employee that the claim is being reviewed for compensability.
• Make compensability determinations within 14 days of receipt of file or an explanation of the issues involved will be prepared for board.
• Determine eligibility for and authorize payment of medical and indemnity benefits on a timely basis.
• Ensure adjuster’s notes include comments regarding exposure, disposition plan for claim closure, financial transactions, supervisor’s notes, and all other relevant claim information.
• Maintain an organized and well-documented file for each reported loss, including a claim specific plan of action with a meaningful resolution plan for each claim incurred which shall be made available for audit by board.
• Provide a comprehensive status report to board at the time any claim exceeds a total incurred value of $50,000.
• Discuss and notify board of denial of compensability of any claim.
• Take financial responsibility for fines, assessments and claims expenses that result from the proposers’ negligent actions.
• Compute and pay temporary disability benefits to all injured or ill employees based on earnings information and authorized disability periods in a timely manner.
• Promptly establish, monitor, and periodically adjust claim-specific reserves through the life of each claim, including adequate and appropriate analyses and notification to board of when reserve is increased in excess of 50% of the prior month’s reserve or by $50,000.
• Prepare, file, and maintain all information and reports as required by the state.
• Arrange for and supervise all necessary investigations to determine eligibility for benefits and liability of negligent third parties.
• Identify and procure the services of experts necessary for the adjustment of claims.
• Experts are to be utilized judiciously for situations such as subrogation recovery or compensability determinations.
• Investigate and pursue all potential subrogation issues on behalf of board.
• Monitor claims closely to prevent program abuse and fraud
• Provide loss control consultation and on-site review on an as needed basis.
- Medical case management
• Provide medical case management of all cases to assure cost-effective and appropriate treatment, including assurance that treatment is related to the compensable injury or illness. Assign medical management on catastrophic claims including brain or spinal cord injury, amputation, sight or hearing loss, major burns, head injury, etc.
• Approve or disallow service requests within the applicable time standards and provide medical advice as warranted.
• Provide timely reports to board outlining utilization review requests, approvals, denials and costs and savings.
• Arrange for medical and legal opinions in disputed cases, conferring with medical examiners, professional personnel, board legal counsel where indicated.
• Maintain close liaison with selected doctors and ensure maximum efficiency in the management of claims by practicing proactive case management and aggressive return-to-duty when clinically feasible.
• Coordinate all medical management services with ancillary service providers as necessary.
• Recommend panels of medical professionals, specialists, and treatment facilities to which injured employees should be referred for IME’s and other consultations.
• Coordinate and ensure continuity, appropriate intensity, quality, and accessibility of services to deter under or over utilization of healthcare resources.
- Intent to Bid Due Date: February 4, 2026
- Questions/Inquires Deadline: January 13, 2026
