Workers’ Compensation TPA Services

The Vendor is required to provide workers’ compensation third-party administration services shall consist of claims administration, claims monitoring, medical case management, and utilization review (UR), and case management to and through resolution of all active past, current and future claims and cases.
- Claim handling
• Handling of all workers compensation claims, including the following:
o Develop and recommend a case management action plan for all new cases.
o File all necessary forms and documents on behalf of the town 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 claim medical liability.
o Request up to date medical reports from providers,
o Investigate all claims for concurrent employment wages,
o Assure medical appointments are kept and reports submitted are timely and complete;
o If no target date for full duty return to work within 30 days, discuss assignment of telephonic and field nurse case manager
o Copies of all legal correspondence, notice of conciliation conference and hearing to be emailed to designated recipients; and
o Strategy call with designated recipients prior to conference or hearing.
• Produce written claim review reports as requested by town for all pending and open lost time claims and attend quarterly claim review meetings of pending workers compensation on-site with representatives designated by the human resources department; quarterly claim reviews are to be scheduled at inception of each new policy period for that particular policy period;
• Produce monthly management reports;
• Actively manage outstanding liabilities and promote case resolution;
• Medical management, including utilization review (UR), scheduling of independent medical examinations (IME) and treatment performance monitoring;
• Control of direct medical treatment costs through preferred provider arrangements with organizations;
• Application of medical cost containment initiatives (e.g., pre-approval for medical services, medical services and pharmacy bill review for justification and payment, utilization review (UR), the use of the lowest state rate setting fees and negotiated fees approved by the town);
• Verification in a manner approved by the town of all submitted claims for mileage or other items ancillary to providing reasonable medical services;
• Recommendation for case resolution and closure, including lump sum settlements, ADR, or formal discontinuance.
- File maintenance:
• Maintain all documentation and files resulting from employee injuries including the department forms, accident reports and wage forms.
• Also maintain all medical reports, attorney letters, notice of third party liens, or any other documentation or files the town deems necessary.
• Administer all past, current and future cases.
• Responsible for all costs associated with the retrieval and copying of documents and files, handling and postage charges.
- Medical reports:
• Obtain all medical and rehabilitation reports, office notes, test results or the like from all treating physicians, Chiropractic, physical and occupational therapists, clinics, hospitals, or any other providers deemed necessary by the town.
- Medical services bill review and payment:
• Examine the bill for appropriateness according to state regulations and - for department of industrial accident claims - utilization review (UR) guidelines,
• Review each bill for usual and customary charges, PPO discounts, duplicate billing, and unbundled charges and adjust each rate to the lowest state rate setting standards or town approved negotiated fees, and
• Place all bills, which have been paid or denied, into the claim file for documentation and mail a copy of the explanation of benefits to the medical provider with a check attached to it, or an explanation why it has not been paid.
• Medical bill processing should take place within 10 business days from the date of receipt.
- Third party liens and subrogation:
• Advise the town on the potential for third party claims.
• Will not settle any third party lien without the prior approval of the town.
- Claims service times:
• Town of claims, the contractor shall maintain business hours and weekdays of operation of at least from 8:30 AM to 4:30 PM ET for Mondays through Fridays.