Third Party Administrator Services

The Vendor is required to provide third party administrator services for include: 
- Contractor requirements
•    Allow the district to retain the sole right to select defense counsel.
•    Comply with all applicable rules and regulations of the centers for Medicare and Medicaid services (CMS), including Medicare, Medicaid, and SCHIP extension act of 2007 (MMSEA) section 111 (mandatory insurer reporting).
•    Provide online claims management system access for ten (10) district users.
•    Import all prior claims data from inception and conduct an audit of the data transfer. 
•    A written audit report shall be provided to the district.
•    Maintain a separate, dedicated bank account for issuing claim payments.
•    Conduct comprehensive claims investigations, including:
o    Contact with the injured employee, medical provider, and supervisor within one business day for indemnity claims; no employee contact required for medical-only claims.
o    Recorded statements for indemnity and denied claims;
o    Analysis of potential third-party liability;
o    Determination of claim compensability.
•    Ensure the timely posting and updating of claim reserves.
•    Obtain the district’s consent prior to denying claims, setting claims, retaining experts, assigning surveillance, assigning nurse case management, and pursuing subrogation.
•    Subcontractor shall audit medical bills in accordance with state fee guidelines.
•    Pay medical bills timely and in compliance with statutory requirements.
•    Ensure the timely filing of all required workers’ compensation (DWC) forms.
•    Comply with state electronic data interchange (EDI) requirements.
•    Adhere to all applicable state and federal laws and regulations.
•    The supervisory file reviews are documented at least every ninety (90) days.
•    The district shall approve the indemnity claims adjuster assigned to its account.
•    Agree that the district or its designated representative shall have the right to audit claims files at any time.
•    On a monthly basis, and upon request, the contractor shall provide a detailed accounting of all incurred costs, including medical expenses, salary continuation, legal fees, expert fees, and all other costs.
•    Immediately provide the district with access to all claims files. 
•    Interface with the district’s safety center system, allowing employees to submit first reports of injury (FROI). 
•    Claims shall be routed to the workers’ compensation specialist prior to being set up in the contractor’s system.
•    Predictive modeling capabilities and projected AI usage.
- Staffing requirements
•    Caseload limitations for an indemnity adjuster are a maximum of 135 claims.
•    Caseload limitations for medical-only adjuster are a maximum of 275 claims
- Service levels
1. System availability
•    Maintain an average monthly system availability of 97% uptime, excluding scheduled maintenance.
2. Advance notice of changes
•    Provide advance notice of any non-emergency system changes as outlined in the services agreement.
•    Accept that the district shall provide fourteen (14) days’ advance notice of non-emergency system changes that may affect services. 
•    Outages caused by district-initiated changes shall not be included in system availability calculations.
3. Customer and telephone support
•    Provide telephone support and designate a primary contact with a direct phone number.