Third Party Administration Services

The Vendor is required to provide third-party administrator’s (“TPA”) services shall consist of claims administration, claims monitoring, medical case management, utilization review (“UR”), and case management to and through resolution of all active past, current, and future claims and cases.
- The services shall include: (1) receipt, processing, filing and maintenance of all claim-related forms, reports and notices as required by state law for controlling losses; (2) UR and verification of all medical services billings, including medications and durable medical equipment; (3) determination of lowest state authorized rate for payments, including claimants granted accidental disability retirement (“ADR”); (4) timely follow-up with doctors and claimants and investigation of cases, when necessary, to reduce exposure and cost; (5) recommendations of appropriate claimant’s earning capacity status for final decision by the city; (6) making direct payments to medical providers on behalf of the city and (7) making direct payments and a voucher system for lost time payments to employees.
- TPA’s services shall also include the incorporation of the appropriate number of nurse case managers to effectively provide advice and assistance in monitoring injured employees’ medical care and treatment and to issue basic reports to claims handlers assigned to the city account and to the city solicitor's office and to department heads, when reasonably requested.
- TPA’s administration of claims shall include receipt, processing, filing, maintenance and payment, directly, or through a voucher system, of all relevant claims, all contact with claimant employees and their legal representatives, all parties involved in treatment and rehabilitation, excluding legal representation before the department, the department reviewing board, the state trial and appellate courts, local and state retirement boards, and the state public employee retirement administration commission. 
- The TPA shall provide the city and, when and as required, the department or any other state agency, timely reports appropriate in format and in electronic media when required so that the reports are reasonably acceptable to the city.
- Claims handling:
•    Handle all matters relative to accidental disability retirement claims, as well as workers’ compensation claims, including the following:
o    Develop and recommend a case management action plan for all new cases. 
o    Collect and review copies of the initial injury report, and the form 101 for workers’ compensation, for facts, completeness and clarity, 
o    File all necessary documents (except form 101) on behalf of the city with the department and other state agencies, 
o    Confirm claim as lost time or no lost time, 
o    Establish liability reserve for compensation and medical services for each claim, 
o    Establish claim status for payment or non-payment pending further review, 
o    Review all no lost time claims for potential medical liability, 
o    Request up to date medical reports from providers, 
o    Investigate all claims for concurrent employment wages, and 
o    Assure medical appointments are kept by employees and reports submitted are timely and complete.
•    Produce quarterly written claim review reports for all pending and open lost time claims and attend quarterly claim review meetings of pending accidental disability retirement claims, as well as workers’ compensation claims, on-site with representatives designated by the city solicitor’s office;
•    Produce monthly management reports;
•    Actively manage outstanding liabilities and promote case resolution;
•    Handle medical management, including utilization review (“UR”), scheduling of independent medical examinations (“IME”) and treatment performance monitoring;
•    Control direct medical treatment costs through preferred provider arrangements with organizations;
•    Apply medical cost containment initiatives (e.g., pre-approval for medical services, medical services and pharmacy bill review for justification and payment, UR, the use of the lowest state rate setting fees and negotiated fees approved by the city);
- File maintenance:
•    The TPA shall maintain all documentation and files resulting from employee injuries, including department forms, accident reports, wage forms, and other forms related to the claim. 
•    The TPA shall also maintain all medical reports, attorney letters, notice of third-party liens, or any other documentation or files the city deems necessary. 
•    The TPA shall administer all past, current and future cases. 
•    The TPA shall be responsible for all costs associated with the retrieval and copying of documents and files, handling and postage charges. 
•    The TPA shall provide remote computer access to the claims files for all cases to the solicitor's office. 
•    All paper files and electronic files and reports are and shall become the property of the city. 
•    TPA will take possession of any paper claim files that are being stored by the current TPA and will arrange for the transportation and storage of these files. 
•    TPA shall complete any programming necessary to incorporate electronic files into its system.
- Claims service times:
•    The TPA shall maintain business hours and weekdays of operation of at least from 8:00 am to 5:00 pm ET for Mondays through Fridays. 
•    The TPA shall maintain a 24 hour a day and 7 days a week telephone call and accident site response service to assist supervisors or managers in their investigations relative to severe acute injuries or hazardous material exposures that may occur during the TPA’s off-business hours.