Workers’ Compensation Third Party Claims Administration and Related Support Services

The Vendor is required to provide workers’ compensation third party claims administration (TPA) and related support services that will meet the needs of the district.
- TPA services the district is looking to procure related services to include loss control services, legal services, and cost containment services.
- Establish a long term business relationship with a successful vendor that can provide proactive plan management service.
•    Third party administration services
•    Legal services
•    Cost containment services
•    Loss control services
- Requirement:
•    TPA, at no additional cost to the district, agrees that the district shall have reasonable access to all claim files. 
•    The ability to have continuous, real time and immediate access to a web-based claims system or risk management information system (RMIS).
•    TPA, at no additional cost to the district, agrees to collaborate with the district regarding language used in standard letters, filings, and documents.
•    TPA, at no additional cost to the district, agrees that the district shall have right, title, interest and ownership of all claim data, statistics, electronic media, and claim files including attendant managed care information assembled in the handling of the account.
•    TPA, at no additional cost to the district, shall periodically (quarterly or semi-annually) meet with district staff to conduct file reviews concerning the district’s active files, claims handling concerns, program operational issues, modified duty program, and other areas of concern.
•    TPA, at no additional cost to the district, shall periodically and upon request provide upper management support to meet and confer with district staff regarding operational and administrative issues.
•    TPA shall add no fees, charges, premiums in any amount to the actual cost to the TPA for subcontracted or vendor services.
•    TPA shall disclose any financial arrangement referencing subcontractors and vendors for the related services sought herein. 
•    TPA’s should highlight any internal profit centers established.
•    TPA, at no additional cost to the district, shall cooperate with the district in identifying duplicate and overpayments made by TPA.
•    Where the reason for duplicate or overpayment is TPA’s failure to act according to generally accepted standards, the TPA shall report to the district on a running monthly basis and make monthly arrangements to reconcile any such overpayments against anticipated fees.
•    TPA, at no cost to the district shall make 3-point contact on all claims.
•    TPA shall set reserves within a reasonable time after on a “most probable” basis, taking into consideration the injury, medical information available, anticipated income benefit exposure and other allocated loss adjustment expenses applicable to the claims handling services.
•    Once exposure is reasonably clear (within the first 30-60 days of handling) TPA shall set reserve at what it considers the life of the file.
•    TPA, at no additional cost to the district, shall assist district in identifying and reporting claims to the district’s excess workers’ compensation carriers as required by the carrier.
•    TPA, at no additional cost to the district, shall provide periodic information to; and cooperate with the district’s actuarial service and loss forecasting evaluations.
•    TPA, at no additional cost to the district, shall provide access to a risk management information (RMIS) claim’s system at district offices for no less than 12 users and provide the attendant training and support.
•    RMIS system capabilities:
o    Accessible via standard internet connection or mobile and pc based platforms; 24 hours a day, 7 days a week, 365 days per year. 
o    Maintain data in a secured manner 
o    Direct claims reporting on new matters by dwc1; and ability to report dwc3 and 6 
o    Provide for usual, necessary, and custom statistical claim information data 
o    Provide for ad hoc reporting based on districts need or request
•    TPA, at no additional cost to the district, shall provide access to and cooperate with independent claims and financial auditors retained by the district and information requested under the state open records act.
•    TPA shall provide electronic access to and notification of plain language notices (PLN) within 24 hours of filing. 
•    TPA, at no additional cost to the district, shall identify, document and pursue contribution and subrogation as necessary within 30 days of receipt of claim. 
•    Any agreement to compromise a lien must be approved beforehand by the district. 
•    TPA shall, at its expense, report to and provide central index bureau (CIB) checks on all indemnity files and medical only files with reserves of $1,500.00 or above.
•    TPA, at no additional cost to the district, shall utilize available resources including designated doctor examinations (DDE); independent medical exams (IME); required medical exams (RME); and peer review in facilitation of the claims handling and administration.
•    “Private investigation,” may be incorporated into the larger scope of claims management and cost containment strategies.
•    TPA shall support and fulfill its role in the district’s modified duty return to work program as outlined in district administrative procedure d13.
•    TPA shall agree to provide full accounting support for the program at no additional cost to the district.
•    TPA shall keep the district apprised of significant developments in the state workers’ compensation rules that may affect the district and provide input as to articles and information to support the employee benefits and risk management office for insertion of materials into district newsletters.
•    TPA shall provide access to employee benefits and risk management staff to TPA sponsored or hosted seminars and continuing education opportunities.
•    Maintaining and documenting weekly contact with injured workers on active lost time claims.
•    Supervisor shall create a claim file workflow to ensure timely claim processing and handling, in accordance with the workers’ compensation act.
•    Payment of medical charges within statutory constraints.
•    Adherence to district vendor management protocols.