Third Party Administrator Claims Services

The Vendor is required to provide third party administrator (TPA) claims services include investigation, evaluation, negotiation, litigation management, and payment of automobile and highway liability claims, as well as loss and trend analysis, and risk management information services.
- Objectives
•    High-quality TPA services that support the state’s automobile and highway liability self-insured program. 
•    Obtaining creative and effective solutions that meet or exceed the goals and requirements 
•    Obtaining proposals that include “life-of-claim” pricing for TPA services. 
•    To ensure the TPA provides a flexible, user-friendly risk management information system (RMIS) that allows efficient access to claim information, supports performance monitoring, and produces routine and customized reports to assist the board in identifying loss trends and causes by state agency.
- Claims management and administration:
•    Claim philosophy
•    First report of injury process including utilization of an automated claim reporting service.
•    Assignment of claims  
•    Criteria for field investigations
•    Claim investigation process
•    Procedures used to detect and manage fraud and the use of surveillance
•    Reserving philosophy and methodology
•    Process for claims evaluation, use of artificial intelligence or knowledge- based systems
•    Medical case management  
•    Settlement policies including structured settlement practices in accordance with the state’s special claims handling instructions. 
•    Procedures for CMS section 111 mandatory Medicare secondary payer reporting
•    Subrogation, indemnification, and management practices
•    Supervisory review
•    Training for all claim handlers  
•    File documentation and maintenance
•    Online edits to delete and prevent duplicate payments and overpayments
•    Procedures for excess carrier notification on behalf of the state. 
•    Procedure for tracking self-insured retention erosion
•    Procedure to monitor TPA’s limited claim reserve and settlement authority within the frequency layer.
•    Special programs using data and analytics that would help the state reduce its claim costs 
•    Procedure to ensure compliance with special claim handling instructions (developed in conjunction with the client agency, its agent of record and TPA which may be updated periodically during the contract term).
- Claims reporting and management:
•    Claim reporting procedures and strategies you utilize to improve the timeliness and accuracy of reporting initial loss information.  
•    Include unique afterhours, catastrophic, serious injury or damages loss reporting processes that will be employed on the state’s account.  
•    The availability of electronic reporting, direct loss reporting and telephone reporting.  
•    Provide a telephone and email for the state to report claims to the TPA.
- RMIS capability
•    Ability to extract and customize data 
•    Ability to identify trends and support loss analysis 
•    Ability to integrate data from other TPAs or carriers 
•    Ability to generate excel-based outputs for state use.
- Claim(s) services:
1. Lifetime claim(s) administration:
•    Manage all assigned claims for their entire duration, from inception through settlement or other discharge, for the per-claim charges.
•    Provide the client agency with instructions for the reporting of claims. 
•    Accept all claim reports from the client agency and establish and maintain a separate file for all claims. 
•    Acknowledge receipt of all claims, identifying each with a file number for future reference.  
•    Inactive claim files will be stored and maintained in a reasonable manner to protect confidentiality of records. 
•    Retain closed claim files as required by law, state retention policy and as otherwise directed in writing by the client agency.
2. CMS claim(s) reporting:
•    The contractor shall adhere to all centers for Medicare and Medicaid services (“CMS”) reporting standards and shall manage and facilitate required filings.
3. Claims investigation and preparation:
•    Perform the necessary investigation and documentation upon which to base a decision regarding liability and damages exposure, and obtain information required for the adjustment of each claim.
•    Provide all personnel required to perform claim(s) investigation(s). 
•    Perform investigations by individuals, rather than by defense attorneys, in the preparation of the defense for claims involving litigation.
•    Provide loss information on claims being handled by contractor. 
•    This loss information must include suggested reserves, payments and the disposition of claims.
•    Maintain a list of healthcare professionals and other specialists for use as necessary for independent examinations and evaluations of claim(s).
•    Analyze each claim and determine the client agency’s rights against third parties. 
•    Writing by the client agency, the contractor shall perform subrogation of claims on behalf of the client agency.
4. Loss adjustment, negotiation and settlement:
•    Compute the payment amount of claim(s) based upon factual investigation, examination and evaluation of the client agency’s liability. 
•    Shall not issue payment to the claimant for each claim without the written approval of client agency. 
•    Shall retain a record of all payments for each claim file.
•    Negotiate with claimant and claimant counsel for claim(s), upon client agency’s written request. 
•    The authority to settle claim(s) of up to a maximum of twenty-five thousand dollars ($25,000.00) when in the contractor’s professional and legal judgement, it is in the best interest of the state or as directed in writing by the client agency. 
•    Any claims settlement(s) of twenty-five thousand and one dollars ($25,001.00) or more must be approved in writing by client agency prior to contractor settling such claim(s).
•    Review all medical bills and all other expenses for other services performed for each claim, for causal relationships of the injury to the accident, and for conformity to medical and surgical fee schedules and charges applicable to the jurisdiction. 
•    Monitor the treatment programs recommended for claimant(s) by physicians and other healthcare providers. 
•    Review all reports prepared by the foregoing parties. 
•    Determine and perform all investigative activities that contractor deems appropriate.