Third-Party Administrator Services

The Vendor is required to provide third-party administrator (TPA) to provide comprehensive workers’ compensation claim management services for all open and prior-year claims, with a focus on effective cost management and high-quality service delivery.
- Program development
•    Transfer, convert and install all new and existing claims information and paper files from prior TPA, if necessary. 
•    The volume of the data includes approximately 10,350 specific claims with 71 specific data fields. 
•    Consult with city staff and assist in developing the necessary procedures, policies, practices and coordination to manage the city’s self-insured workers’ compensation program and to meet the applicable workers’ compensation laws. 
•    Establish procedures and provide necessary documentation of payment of benefits, medical expenses, legal fees, and other related costs. 
•    Assist in preparing a manual for use by first line supervisor(s) regarding workers’ compensation policies and procedures. 
•    Provide experienced claims examiners to manage an average of 180 claim files each. 
•    Claims examiners must have a minimum of 5 years examiner level, experience and must possess a self-insured certification for the state.
- Claims administration
•    Review and process all reported claims for workers’ compensation benefits in accordance with the requirement of the state division of workers’ compensation and coordinate with any related state and federal applicable laws. 
•    Determine and advise the city regarding the compensability of claimed injuries and illnesses in accordance with applicable workers’ compensation laws.
•    All recommended delayed claims must be discussed with the workers’ compensation supervisor prior to delaying. 
•    Advanced notice, explanation and approval is needed for all denied claims. 
•    All denials must be based on substantial and clearly documented evidence supported by applicable workers’ compensation laws. 
•    Represent the city’s interest in all subrogation cases relating to workers’ compensation claim and coordinate with the city’s workers’ compensation supervisor and city’s legal claims coordinator, as necessary. 
•    All self-imposed penalties must be reported to the city monthly. 
•    Penalties incurred because of the failure of the TPA to comply with statutory laws and regulations shall be the sole responsibility of the TPA. 
•    Manage claims under the direct supervision of the city’s workers’ compensation supervisor. 
•    Provide city staff with full access to the vendor's claims management system for the administration of the city administered claims.
- Medical control
•    Refer injured employees to city’s designated initial treatment facilities for the initial treatment of injured employees. 
•    Make regular contact, including returning calls within a 24-hour period, with the injured employee to help maintain a positive rapport in the case of continued disability. 
•    Consult with city’s return to work (RTW) examiner to obtain status of light or modified duty assignment for employees who are unable to return to full duty. 
•    Notify city’s excess workers’ compensation liability insurer of claims as specified and coordinate the investigation and settlement of these claims with the excess insurance carrier.
- Employee services
•    Contact employees on all new injuries within 24 hours of notice of claim to discuss specifics of the injury and other relevant information required for the appropriate claim administering of the claim. 
•    Inform employees of their rights and benefits, answer workers’ compensation questions, and make every effort to develop a rapport with employees throughout the claims process. 
•    Contact employee’s immediate supervisor and manager within 24 hours of notice of claim. 
•    Inform supervisor and manager of employee’s rights and benefits. 
•    Obtain information from supervisor and manager regarding specifics of injury and answer any questions regarding the claims process. 
•    Assist in resolving employee problems related to the industrial injury in non-litigated cases. 
•    Provide information and guidance regarding benefits, notices, inquiries on specific injuries and permanent disability ratings.
- Management component
•    Provide the city quarterly claim narratives and management reports and attend file reviews with city departments upon request to discuss the objectives, accomplishments and plan of action on injury claims. 
•    This review should include any issues identified by the TPA or the city. 
•    The review should include, but not limited to, claims observations and recommendation, status of litigation, subrogation and objectives for the coming quarter. 
•    Submit monthly loss run reports to include, but not limited to, number of open claims, number of closed claims, reserve analysis, list of claims by department, list of penalties paid out, and list of recoveries. 
•    Complete an annual review of all open claims with reserves information. 
•    Reconcile or correct any database coding entries and provide the city a report of findings by end of fiscal year, June 30. 
•    Assist in establishing realistic reserve levels per claim. 
•    Prepare and submit statistical data no later than September 1 for the preceding fiscal year, to the city for the public self-insurer’s annual report, due by October 1 of each year. 
•    Prepare and submit statistical data no later than March 1 for the preceding calendar year, to the city for the annual report of inventory, due by April 1 of each year. 
•    Provide the city with all information required for the alternative dispute resolution (ADR) annual report by March 1st that is required by April 1 of each year.
- Risk information management system (RIMS)
•    Provide reliable access to financial and administrative data regarding all claim files via secured website or VPN connectivity. 
•    Provide a quarterly download of all claim data in ASCII fixed field length file format, as specified by the city, to provide for the development of reports unique to the city’s requirements. 
•    Ensure all city claim data utilizes city employee numbers and city assigned incident control numbers. 
•    Provide definitions of all codes associated with city claim data. 
•    Submit samples of its regular monthly, quarterly, semi-annual and annual computer runs and reports, and provide an index of all available computer reports.