Third Party Administration Services

The Vendor is required to provide third party claims adjusting services (TPA) for workers compensation and employers liability.
- Claim and risk management services
1. Access to claims files:
• Entity shall have reasonable access to their respective claim files created as a result of claims services to be provided by the successful consultant.
• Reasonable access shall include making available upon five (5) days written notice, all claim files for review by the entity, or their designated claims auditor, at the claim office providing the services on the files.
• Upon written notice by the entity, the successful consultant shall make available to the named requesting entity within ten (10) days after written request, a complete copy of selected files identified by the requesting entity or their representative.
2. Ownership of claim files:
• The entity shall have the right, title, interest and ownership of their respective claim files created as a result of claims services to be provided by the successful consultant.
• At the sole option of the entity, and upon ten (10) days written notice, the successful consultant shall return such files to the named insured.
- Workers’ compensation and employer’s liability:
1. Compliance with rules of division of workers’ compensation:
• Workers’ compensation to provide risk management services in the state.
• Services rendered must fully comply with any and all applicable rules established by the department of labor and employment security including but not limited to those rules.
2. Administrative services:
• Prepare, maintain and file all records and reports as may be required by legal authorities (state, local, and federal).
• Maintain and file statistical or other records and reports as required by excess insurers
• Prepare, maintain and file statistical information required by the workers’ compensation rating bureau or appropriate state agency, including that date necessary for the promulgation of experience modifications.
• Maintain and file payroll and premium audits.
• Comply fully with all rules, regulations, guidelines or procedures established by the state and any applicable amendments thereto.
• Place excess insurers on notice of claims pursuant to requirements outlined in such insuring agreements drafted pursuant
• Claims as requested with the city designated legal counsel.
• Investigative services and other “expert” services as needed.
• Be available in person or via telephone to attend mediation conferences.
• Handle to conclusion all run off claims.
3. Claims services:
• Establish claim and loss files for each reported claim and loss.
• Such files are subject to review and audit by the client at any reasonable time.
• Establish reporting procedures, which are compatible with the needs and organizational structure of the entity.
• Such forms are to include appropriate first reports of injury with mailing address of primary recipients preprinted thereon.
• Receive and examine on behalf of the entity reports of employee injury claims.
• Accept or deny reported claims for employee injuries on behalf of the entity in accordance with applicable workers’ compensation laws.
• If it appears that the final value of any claim settlement will exceed a discretionary limit of $5,000 or may be of a nature that is sensitive to the organization, the final decision to accept or deny shall rest with the entity, or its respective designees.
• Subject to the prior approval of, and at the expense of the entity, employ outside professionals such as private detectives and expert witnesses to assist in the investigation and adjustment of claims.
• Review for reasonable and conformity to appropriate medical and surgical fee schedules all medical bills and other services for which a claim is being made.
• The foregoing provisions, pay in accordance with state regulations or, lacking that, in a timely fashion all claims and expenses.
• Aggressively pursue all possibilities of subrogation with entity approval (for all lines of coverage), contribution, indemnity and recovery from special or second injury funds on behalf of the entity.
• Additional fees (if any) for this service should be outlined on the proposal forms under time and expense.
• Provide assistance in providing rehabilitation of injured employees in consultation, retraining or reassignment of employees with limited physical performance arising out of covered injuries.
• Consult with and refer to the entity, or its respective designees all questionable or contested cases and those with an estimated value in excess of $5,000.
• Maintain a current roster of preferred physicians and other medical professionals for treatment of covered injuries on a first aid and specialized basis as well as maintaining procedures for establishing close liaison with the treating physicians and other medical professionals.