Workers' Compensation Services

The Vendor is required to provide workers’ compensation program services, which may include fully insured workers’ compensation coverage, third-party claims administration services, excess insurance placement, medical management services, loss control services, risk financing alternatives, and related professional services.
- Claims administration
• Receive and acknowledge all new claims reported by the city and establish claim files in the contractor’s claims management system.
• Conduct timely and thorough investigations of reported injuries or illnesses to determine compensability.
• Make compensability determinations in accordance with state workers’ compensation law.
• Manage all medical and indemnity benefits associated with accepted claims
• Coordinate with medical providers to ensure appropriate treatment and cost control.
• Manage litigation activities, including coordination with legal counsel when claims are disputed or litigated.
• Maintain complete and accurate claim documentation and records for all claims administered on behalf of the city.
• Establish, maintain, and adjust claim reserves in accordance with industry best practices and shall maintain documented reserve authority procedures.
• Reserve changes shall be documented with supporting rationale.
• Formal reserve review no less than quarterly.
• Disclose reserve authority and settlement authority levels.
- Adjuster requirements
• Assign at least one dedicated workers’ compensation adjuster responsible for administering the city’s claims.
• Designate a backup adjuster to provide coverage during periods of absence or workload fluctuations.
• All adjusters assigned to the city’s program shall maintain appropriate state adjuster licensing, where applicable.
• Maintain adjuster staffing levels sufficient to ensure timely claims handling and compliance with all service standards.
• The city with the names, qualifications, and contact information of all adjusters assigned to the city’s program.
• Notify the city in writing prior to any reassignment or replacement of the primary adjuster assigned to the city.
• The city reserves the right to request reassignment of adjusters whose performance fails to meet service expectations.
• Assigned personnel shall not be removed or replaced without prior written approval from the city, except in cases of termination, resignation, or unavoidable circumstances.
• Disclose average caseloads maintained by adjusters assigned to workers’ compensation claims.
• Average caseloads maintained must include, but not be limited to, the following:
• Medical only
• Indemnity
• Litigated
• Catastrophic
• Identify average open medical only and indemnity claim counts assigned to the primary adjuster proposed for the city.
• Disclose reserve authority and settlement authority levels applicable to adjusters assigned to the city’s account.
- Medical management
• Medical management services including, but not limited to, the following:
• Nurse case management services when medically appropriate.
• Access to a preferred provider organization (PPO) or other medical network designed to control medical costs while maintaining quality care.
• Pharmacy benefit management services designed to monitor and manage prescription drug utilization.
• Utilization review services to evaluate the necessity and appropriateness of medical treatment.
• Medical bill review services.
• Medical management services comply with applicable state workers’ compensation laws and regulations
• Identify average medical savings achieved through bill review, utilization review, pharmacy management, and network discounts.