Workers’ Compensation Third Party Administrator Services

The Vendor is required to provide third party administrative (“TPA”) workers’ compensation services for agency.
- Core Claims Administration
•    Review and process all workers’ compensation claims. Conduct necessary investigations in consultation with the District and maintain appropriately documented files.
•    Establish and maintain reserves on the basis of most probable final cost. Immediately notify District Risk Management when an adjuster increases a claim reserve by more than $10,000.
•    Admit or deny claims with prior District approval, in accordance with statutory guidelines and medical analyses.
•    Pay disability benefits on admitted cases in a timely manner. Confirm medical verification of continuing disability before payment.
•    Obtain medical reports and pay bills as required by statute. Monitor treatment for appropriateness and cost-effectiveness.
- Legal & Specialized Services
•    Outline claim strategies regarding defense and handling. Refer claims to authorized counsel from the District’s approved panel and assist with the defense of litigated cases.
•    Attend hearings, pre-hearings, and settlement conferences as needed.
•    Investigate and refer files for subrogation where appropriate. Refer cases to vocational rehabilitation per State requirements.
•    Utilize specialized strategies (e.g., "Grover-eligible" identification) to move claims toward full and final settlement and prevent "maintenance creep."
- Data, Analytics & Reporting
•    Provide monthly cumulative check registers (medical, indemnity, and expenses) and 1099s to vendors.
•    Provide full transparency of all fees (Monthly/Annual, Per Claim, Special Project, and File Conversion).
•    Provide monthly performance/experience reporting with trend analysis, annual benchmarking, and data for experience modification factor calculations.
•    Provide District staff with real-time access for claim entry, viewing claim information, and reviewing adjuster notes.