Worker's Compensation Third Party Administration Claims Management Services

The Vendor is required to provide worker's compensation third party administration claims management services to maintain and adequately staff an on-site facility shall be a material breach of the contract and will be subject to penalty as outlined in the performance guarantees.
- General file management
• Claims will be set up by contractor and at the adjuster's desk within one business day of receipt of legal notice of a new injury (either form 102 or form 101/407).
• Adjusters will make three-point contact with the city, injured worker, and provider’s office on every claim within one business day of receipt of each claim on their desk.
• Adjusters will return all phone calls from city employees or medical providers within one business day.
• All attempts to return phone calls will be documented in the claim notes.
• If an adjuster is out of the office, an out of office auto-reply shall be put in place.
• Adjusters will secure recorded interviews on all claims that require thorough background information.
• This includes but is not limited to: claims involving preexisting or underlying conditions, claims involving injuries that require specialist referral, injuries that are under investigation for any reason, and injuries that require detailed information regarding negligent third parties.
• Adjusters will immediately request all prior medical records on all claims that are being investigated for compensability and are suspected, within the first seven days of the investigation, to potentially become lost time claims.
• Adjusters will contact the city no later than seven calendar days prior to a potential claim denial due to the expiration of a 21-day notice from the commission.
• All calls from medical providers requesting first-fill prescription authorizations, physical therapy authorizations, or medical diagnostics authorizations for treatment being provided to a city employee under a new injury claim prior to the establishment of a claim file at contractor's office will be routed to contractor’s supervisor.
- Additional claims administration requirements
• The city retains the right to exclude all ancillary providers recommended by contractor and to agree or disagree with ancillary services recommended by contractor, including but not limited to pharmacy programs, durable medical equipment providers, IME companies, defense attorneys, and surveillance companies.
• Awarded under a per claim charge, contractor will only charge a specified per incident rate for first aid only claims.
• Report all city claims that fall within the federal reporting guidelines to the centers for Medicare and MEDICAID services (CMS) as required by the Medicare secondary payer (MSP) act of 2007, effective July 1, 2009.
• Claim forms for the reporting of all occupational incidents, injuries, and diseases to the proper state regulatory agency and recommend procedures for prompt reporting.
• Recommend attorneys to assist in any case where legal representation is desired and will consult with and furnish available claim information to any attorney chosen.