Workers’ Compensation Administration Services

The Vendor is required to provide third-party administrator for the ulster county self-insurance plan (the “plan”).
- Requirement:
• Prepare self-insured employers workers' compensation forms.
• Attend meetings as requested by the county insurance department.
• Prepare and file all workers' compensation claim forms.
• Continue the investigation, evaluation and disposition of claims turned over to firm prior to commencement of this agreement.
• Investigate, evaluate, and dispose of all claims occurring during the term of this agreement.
• Establish and maintain complete claim files (including an electronic file) and supervise all claim litigation for each claim received.
• Examine and investigate each claim to establish compensability and liability within fourteen (14) days of receipt from the county.
• Audit and evaluate each claim and perform all required administrative and clerical functions for each claim.
• Firm shall complete, file and serve on all necessary parties all forms and notices required to be filed and served and provide initial reserve recommendations within thirty (30) days of receipt of assignment from county.
• Promptly notify the county of an increase or decrease of $25,000.00 or more in the claim reserves.
• Prepare and mail compensation payment drafts or checks to claimants and claimant's attorneys.
• Recommend and coordinate the negotiation and settlement of claims.
• All settlements must be approved by the county prior to offer.
• Prepare and provide monthly or more frequently if requested by the county reports of accidents that have been reported to the firm by the county, together with cost summaries, loss runs and expense reports.
• Reports must include but are not limited to the following:
o Claimant name;
o Claimant location;
o Brief accident description;
o Nature of injury;
o Body part affected;
o Social security number;
o Date of loss;
o Date claim received;
o Indemnity reserves, paid and incurred;
o Medical reserves, paid and incurred; and
o Administration expense reserves paid and incurred.
• Refer claims involving administrative or court proceedings identified by the county to legal counsel which has been selected by the county.
• The firm shall cooperate with the counsel selected by the county.
• The cost for legal counsel related to administrative or court proceedings shall be treated as a claim file expense.
• Prepare claims and arrange for licensed or legal representation at workers' compensation hearings before administrative law judges of the workers' compensation board, with the cost of such representation being paid as a claim file expense.
• Retain qualified counsel to execute appeals when approved by the county.
• Representation at workers' compensation board panel hearings, with such expense to be treated as a claim file expense.
• Recommend legal counsel to the county in the event of an appeal to an appellate court has been approved by the county.
• The expenses for preparation and filing of the appeal, printing of the record, presenting argument to the court, and miscellaneous legal expenses are to be paid as a claim file expense.
• Nurse case management when the firm and the county deem it is in the county's best interest.
• Case management expenses are to be paid as a claim file expense.
• Vocational rehabilitation when the firm and the county deem it is in the county's best interest.
• Vocational rehabilitation expenses are to be paid as a claim file expense.
• Arrange for the review of all medical bills for conformance with the state workers' compensation fee schedule and reducing these bills to the proper amount when the fee schedule is exceeded.
• Fees for this service shall be paid as a claim file expense.