Workers Compensation Claim Administrator Services

The Vendor is required to provide or the day-to-day operations of the City’s Workers’ Compensation Program resides with the City’s Office of Health and Safety.
- The workers’ compensation claims are managed currently by a third-party administrator using proprietary software.
- The Third-Party Administrator will coordinate and continually monitor the active modified duty and return to work program and facilitate the transition from time loss to regular duty status.
- The firm’s computer capability and include sample automated claims administration reports.
- A transition plan that will minimize the impact of a new program on the self-insured worker’s compensation program in the City.
- The duties and responsibilities of the adjudicator shall be as follows:
•    Review all claims or loss reports made by City and/or claimant for injury, illnesses, or death.
•    Investigate (photos, statements, reports, etc.) all claims made against City.
•    Arrange for surveillance or activity checks as deemed appropriate and upon approval by City.
•    Assist City in preparing the defense of litigated cases.
•    Attend trials and/or settlement conferences as requested by City.
•    Develop and maintain a file on each claim or loss in accordance with specified City guidelines. Make sure files are available for review by City or its designee upon request. When requested by City, prepare a case summary on each claim.
•    Notify excess insurers of claims or occurrences that may potentially approach the agency’s peroccurrence retention, and if requested, provide information of the status of those claims to such insurers.
•    Develop and maintain a claims database to be used in the administration of claims and to generate reports. This database must include all items specified in Statistical Reporting for Workers Compensation Claims Administration Service document.
•    Within 15 days following the end of each month, provide City a report to account for individual claims and aggregate loss experience analysis. The report shall include all incident reports and their status.
•    Upon request, furnish City with additional data necessary to prepare financial and statistical reports on losses or claims.
•    Upon request, provide information on methods and controls used in claims administration.
•    Respond to inquiries from employees regarding the status of their claims against City.
•    Assist with training appropriate City staff on proper claims handling procedures, as requested.
•    Provide claims handling materials as appropriate (i.e. claims reporting kits, ID cards, etc.).
•    Assume responsibility for subrogating all cases where a potential recovery exists, including investigation, evaluation, and negotiation of all subrogation cases.
•    Assume all open claims from the contract execution date.
•    Attend quarterly “experience” meetings with City management staff.
•    Be available for frequent requests for information and other duties as requested.
•    Prepare all administrative reports required by State or the Federal Government including MediCare. Monitor the compliance of City’s employer reporting requirements and record keeping requirements and advise of any deficiencies in City’s overall self-insured compliance matters.
•    Prepare all appropriate responses to audits and inquiries of all regulatory agencies.
•    Receive, maintain, adjust, and issue all claim related payments for bills/payment to City; to include, but not limited to, medical bills, time loss benefits, permanent partial disability payments, travel pay, and prescription reimbursement.
•    Maintain accurate records to reflect all transactions and disbursements done on behalf of the City. At City’s request, provide City copies of all related financial records for auditing purposes.
•    Establish and adjust as appropriate, reserves levels for all previous and new claims.
•    Prepare and provide to City, periodic (at least quarterly) graphic display reports on trend analysis of claims history by frequency, severity, medical only, time-loss, and medical costs. For the purpose of billing and this contract, “Time Loss Claims” is defined as any claim that qualifies for time loss payment (not sick leave) or a partial permanent disability (PPD) payment.