Workers' Compensation Medical Bill Review Services

The Vendor is required to provide state­ of-the-art workers' compensation medical bill review services
- Provide a brief summary of your company’s history with providing Workers' Compensation Bill Review services to Public Agencies and the contractor's capabilities in performing Workers' Compensation Bill Review services to Public Agencies.
- Review and re-price all medical bills submitted by the City in compliance with State mandated timeframes using the state Official Medical Fee Schedule (OMFS); usual, customary and reasonable rates (UCR); Preferred Provider Organization (PPO) contract rates; and/or other negotiated contract rates within five (5) business days.
- Identify all duplicate billings and ensure that duplicate payments are not made.
- Deny all charges for all items not required for the injury described.
- Identify all unauthorized charges to ensure billing does not exceed the parameters of an injured worker's treatment plan, Utilization Review certifications and Managed Care services.
- Provide an Explanation of Benefits (EOB) for each bill reviewed.
- Protect appropriate copies of City Data from loss, corruption, or unauthorized alteration; and
- Prevent the disclosure of City and Contractor passwords and other access control information
- Separation of Duties: Contractor shall divide functions among its staff members to reduce the risk of one person committing fraud undetected.
- Role-Based Security: Contractor shall restrict access to authorized users and base access control on the role a user plays in an organization.
- Payment Instruction Generation: Automated creation and delivery of payment instructions to the TPA claim system that:
•    Identifies the payee (provider or lien claimant), payee tax ID, remittance address/ACH details;
•    Itemizes the net payable medical amount and any interest/penalties;
•    Excludes Contractor fees from provider payments and instead generate a separate payment instruction for Contractor fees; and
•    Supports consolidated and split payments per claim, per provider, and per bill as configured.
- Separate Fee Payment Workflow: Ensure Contractor’s bill review and/or lien resolution fee(s) are captured, transmitted, and paid through a distinct payment issuance event linked to the adjudicated bill/lien record and visible in the TPA claim financials and remittance reporting.
- Provider/Lien Payment: Upon adjudication approval, the MBR/Lien system shall trigger a payment instruction to the TPA claim system for the medical payable amount (including interest/penalties) to the provider or lien claimant.
- Produce compliant EORs and support lien workflows, appeals, and settlement processes.