Workers' Compensation Third Party Administrator Services

The Vendor is required to provide workers' compensation third party administrator services for include:
- Claims administration services
1. Assumption of existing claims
•    Assume responsibility for all open workers’ compensation claims at the start of the contract term.
•    Oversee the transition from the previous third party administrator, import historic files, and ensure continuity of service.
2. Claims processing
•    Process all claims in accordance with applicable state labor code regulations and city policies and procedures.
•    Assign experienced adjusters to each claim, ensuring adjusters have necessary experience and training in workers’ compensation claims management; specifically, experience with public entities.
•    Within 24 hours of receipt and notice of employer’s report of injury, adjusters shall conduct intake meetings with injured employees, set up appropriate claim files, and coordinate with city risk analyst.
•    Manage care coordination and facilitate timely return-to-work programs.
•    Engage the services of medical providers including physicians, therapists, pharmacists, and investigators, defense attorneys, hearing representatives and other firms or individuals to performed specialized work in connection with claims administration.
•    Proactive claims management: TPA will provide consistent and proactive oversight of claims, ensure timely action on required filings and payments, and promptly identify and address issues.
- Medical management
•    Obtain and review all medical reports for each claim.
•    Conduct ongoing verification of workers’ compensation indemnity payments with medical providers. 
•    Provide medical bill review services either in-house or via an independent firm (with prior HR approval) to ensure compliance with the medical fee schedule.
- Utilization review (UR)
•    Reviewing treatment requests for medical necessity, appropriateness, and compliance with state labor code. 
•    Coordinating with an independent UR provider if required. 
•    Ensuring timely approvals or denials per statutory timelines. 
•    Communicating UR decisions to treating providers, claimants, and city staff. 
•    Maintaining complete documentation of all UR activities in the claim file and portal.
- Claim payments and reserves
•    Make timely payments to claimants and service providers on behalf of the city. 
•    Estimate and maintain claim reserves based on the most probable final claim cost. 
•    All reserve categories shall be reviewed on a regular basis but not less than at least every forty-five (45) calendar days for active claims and six (6) months on claims that have settled but are open to monitor future medical cases.
- Settlements and claim resolution
•    The TPA shall prepare comprehensive settlement reports for all claims where settlement is considered. 
•    Each report shall include:
o    A detailed claim summary, including medical treatment, indemnity payments, and any other related costs. 
o    Settlement options, including recommended amounts, structured or lump-sum options, and potential impact on reserves. 
o    TPA’S professional recommendation regarding whether to settle, continue litigation, or pursue alternative resolution strategies.
•    The TPA shall obtain all necessary approvals from city staff before finalizing any settlement. 
•    Maintain detailed documentation of all settlement negotiations, offers, and agreements for record-keeping and regulatory compliance.
- Litigation support
•    Selection of defense counsel or hearing representatives: provide recommendations and assist in evaluating potential firms or individuals. 
•    Coordination with legal counsel: act as the primary liaison between the city and defense attorneys, ensuring timely exchange of claim information, documentation, and evidence. 
•    Strategic guidance: support legal counsel on developing litigation strategy, potential outcomes, and cost implications. 
•    Resolution support: work with legal counsel to negotiate settlements, prepare reports for city approval, and ensure claims are resolved efficiently and in compliance with regulations.
- Customer service, technology, and communication
•    Respond to standard city inquiries within 24 hours, high-priority issues within 4 hours. 
•    Emergency availability: the TPA shall at all times have the examiner assigned to the city, or in their absence, the supervisor or another manager, available by telephone for emergencies through a 24-hour emergency telephone number. 
•    Ensure that at least one or more examiners assigned to the city is available to the city every business day throughout the term of the contract. 
•    Establish escalation protocol for urgent or unresolved issues. 
•    Provide a secure, web-based claims management system and portal providing authorized city staff with timely access to claim status updates, work status, relevant claim notes, documents, payment history, and reported injuries with no medical treatment. 
•    Portal must support reporting, data export, and automatic intake of data files from our systems.