Third-Party Claims Administration and Workers Compensation Services

The Vendor is required to provide third-party administrator (TPA) and workers compensation that aligns with our philosophy of meeting the reasonable, necessary, and related medical needs of our injured workers to facilitate an expedient and healthy return to work.
- Compliance with rules of workers' compensation
• Responsibility of the proposer to comply with all rules and regulations promulgated by the various state agencies that prescribe the practices and procedures of self-insurer service companies.
- Medical management/control standards
• Bill payment - proposer will review bills, invoices, and other claims for payment submitted by health care providers to identify proper authorization, over utilization, underutilization and billing errors and will adjudicate/pay those bills and mail (postmark) payments within 20 days.
• Bills will be properly coded per medically accepted ICD (international classification of diseases) and CPT (current procedural terminology) codes.
- Claims management
• Claim receipt, screening, and assignment - appropriate claims and medical resources are assigned to maximize the effectiveness of benefits delivery and claim resolution in accordance with mutually agreed-upon criteria.
• Timely reporting, quality contact - adjuster will make timely (within 24 hours but not later than the next business day, excluding weekends and holidays), appropriate, and meaningful contact with the injured employee, site supervisor, and physician.
• The file will document this contact.
• If contact is not made, the file will document attempts at contact.
• Documentation will include, but not be limited to, documentation of compensability, mechanism of injury, medical necessity of medical care, orientation of the injured worker, duty status, as well as evidence of meaningful medical, educational, vocational, and societal background information relevant to the ability of the injured employee to return to his or her usual occupation and recording statement.
• Communication - evidence/documentation of routine and effective communication between all interested parties involved in the claim: adjuster, nurse case manager, physicians and other health care providers, employer, employee, legal counsel, etc.
• Information requested from interested parties should be aggressively pursued.
• The information is not provided in a reasonable amount of time, follow-ups for the requested information should be sent at regular intervals until the information is provided or the matter is otherwise resolved.
• The file should be clearly documented with the date and description of each new request or follow-up.
- Required services
• Administrative services,
• Claims services,
• Telephonic case management services,
• First notice of injury services,
• Loss statistic services,
• Network access,
• Medical bill review and audit services,
• Field case management services (separate fee will apply)
• Pharmaceutical benefit management services.