Workers’ Compensation Claims Administration and Managed Care Services

The vendor required to provide workers’ compensation claims administration and managed care services for include:
- Caseload, case review, documentation and claim handling
•    Each examiner shall have a caseload within a range of 125 to 140 open indemnity claims, which includes future medical claims. 
•    If the caseload contains medical only claims, two medical only claims shall equal one active indemnity claim.
•    Each claim file shall contain the examiner’s plan of action for the handling of that claim. 
•    Such plan shall be documented electronically. 
•    The initial plan of action will be clearly documented in the system within 14 calendar days of the initial claim set-up. 
•    The plan of action will be updated at least every 90 calendar days and clearly identified in the system. 
•    Consultant will investigate questionable claims with coordination, assistance and approval from the city.
- ISO and EDEX
•    The TPA shall subscribe to the iso, or other recommended organizations in order to obtain background history on individual claims. 
•    Costs to subscribe to these services shall be included in the pricing structure. 
•    The examiner shall request a report from iso, or other recommended organizations on all new indemnity claims. 
•    Subsequent requests should be made every six to 12 months thereafter on all active indemnity claims.
- Investigations
•    The TPA shall promptly initiate investigation of issues identified as material to potential litigation. 
•    The city shall be alerted to the need for an outside investigation as soon as possible and the city will appoint an investigator, however the TPA can refer a trusted investigator also. 
•    The city shall be kept informed on the scope and results of all investigations. 
•    All activities shall be clearly documented in the computer system.
- Provision of benefits
•    The TPA shall provide all compensation and medical benefits in a timely manner and in compliance with the statutory requirements of the state labor code. 
•    The TPA shall compute and pay temporary disability benefits to injured employees based upon earnings information and authorized disability periods. 
•    The TPA shall review, compute and pay all informal ratings, death benefits, life pensions.
- Initial indemnity payment
•    The initial indemnity payment or voucher will be issued and mailed to the injured employee together with a properly completed DWC benefit notice within fourteen calendar days of the first day of disability. 
•    Copies of benefit notices will be maintained in the applicable claim file.
•    Late payments must include the self-imposed 10% penalty in accordance with labor code. 
•    If late due to TPA, TPA assumes all late payment penalties.
- Permanent disability
•    The TPA shall arrange for an informal disability rating such as “speed rating” whenever possible to avoid board litigation. 
•    The TPA shall take advantage of any potential apportionment potential to prior claims, disabilities, and impairments. 
•    The TPA shall also advise the city of potential credits and penalties to permanent disability benefits should the city accommodate permanent and alternative work for at least twelve months.
•    All permanent disability benefit notices shall be sent to the employee as required by the state labor code. 
•    Copies of benefit notices will be maintained in the applicable claim file.
- Claim reconciliation
•    All claim files shall be reconciled to ensure correct indemnity payments. 
•    The reconciliation should verify that payments were made in the correct amount and from the correct claim file. 
•    All open claim files shall be reconciled at the time of a request for settlement authorization and at the time of submission for closure. 
•    Proof of the reconciliation should remain in the claim file and clearly documented in the computer system.
- Claims reporting
•    The TPA will provide monthly statistical data and reports – content to be established between the TPA and the city. 
•    The TPA will provide other special reports required of the city of including, but not limited to, loss trend reports, claim abstract reports, reports required by actuaries, excess insurance carriers, etc., provided that such reports do not require data elements that have not previously been collected by the TPA. 
•    If new programming is required in order to provide such reports, the TPA shall pay at its own expense for new or special programming costs.
•    The TPA on behalf of the city, shall prepare and file all reports, forms and other documents in a timely manner which are now or will be required by the state or other governmental agencies relating to workers’ compensation claims, including but not limited to the self-insurer’s annual report. 
•    TPA will present all reports to the city 30 days in advance of their due date.