Worker's Compensation Special Claims Administration Services

The Vendor is required to provide self-insured, self-administered for Workers’ Compensation insurance.
- County’s workers’ compensation claims are managed by the Department.
- Process assigned workers’ compensation claims from date of injury through final disposition and continue if future medical care is applicable, or until the county notifies contractor to cease.
- Provide facilities, equipment, staff, and supervision for the purpose of special claims administration in accordance to state labor code and public risk innovation, solutions, and management (PRISM) standards.
- Hold regular business hours, excluding County holidays, typically Monday – Friday, 8:00 AM – 5:00 PM Pacific Time Zone.
- Contact the injured employee, County liaison, and medical providers if appropriate, within 3 working days of claim receipt.
- Provide access to all records related to this contract for County quality assurance reviews on a random basis.
- Review cases on a periodic basis, typically between thirty to ninety (30 – 90) days, (commonly referred to as “diary”) and perform reasonable claims resolutions activities on those review dates.
- Set appropriate reserves, for a reasonably expected outcome, and promptly communicate the reserves to the County liaison for input into the County’s claims management system.
- Provide exceptional customer service by responding to communication from injured workers and medical providers as soon as possible, ideally same-day, and responding to the County within one business day.
- Consult with the County liaison for approval to assign legal counsel.
- Provide loss run, payment report, and check register electronically to the County liaison monthly.
- Provide injured workers’ medical reports within then 10 business days to the County liaison.
- Provide Explanation of Benefits to providers within 30 days