The vendor required to provide workers compensation third-party administrators (TPAs) to ensure that all worker’s compensation claims are handled in accordance with the rules and regulations established by the state of board.
workers’ compensation core services include claims administration and adjudication, medical management, medical bill review and re-pricing, physician peer-to-peer services, and utilization review nurse services
- Responders must agree to provide all the following services:
• Administrative services.
• Claims services.
• First notice of injury services.
• Loss statistic services.
• Organization services to include:
o Network access and development services
o Triage
o Telephonic case management and (when appropriate and agreed upon, site case management)
o Pharmaceutical benefit management services
o Communicable disease management program services.
o Utilization review, including:
1. Medical bill review and audit services
2. Pre-certification
3. Concurrent and retrospective review
o Peer-to-peer review
• Loss control services.
- Claims adjusting services
• Provide claims administration organization including, but not limited to, years of experience and percentage of public vs. private entity clients.
• The annual volume of newly reported workers’ compensation claims handled by your organization annually
• The assigned claims staff be dedicated to city claims
• Adjusters identify and manage potentially fraudulent claims.
• Review open workers’ compensation claims and provide directions to adjusters
• Provide ongoing action plans that include specific steps to bring the file to resolution and closure
• Capabilities for assisting clients in obtaining reasonable accommodation from treating physicians for injured workers
• Litigation management strategies, including your organization’s policy regarding referral to legal counsel.
