Workers’ Compensation Claims Administration and Risk Management Services

The Vendor is required to provide workers' compensation administration TPA must perform the following core functions:
- Core claims administration
• Compliance: administer all claims strictly in accordance with the state workers’ compensation act, statutory updates, and state regulations.
• Intake and investigation: review all first report of injury (FROI).
• Initiate contact with the injured employee within one (1) business day of receipt. Investigate questionable cases and determine compensability promptly.
• Three-point contact: establish early communication with the injured employee, supervisor, and treating medical provider.
• Reserving: establish and maintain accurate, realistic claim reserve levels utilizing industry standard actuarial practices.
• Reserves established within 30 days of the FROI.
• Disability management: authorize examinations to determine the nature/extent of disability.
• Calculate and authorize temporary total, temporary partial, permanent partial disability, and death benefits.
• Medical management: utilization review, nurse case management, when authorized, pharmacy benefits management coordination.
• Litigation and dispute management: coordinate with corporation counsel and director of human resources regarding workers compensation commission hearing representation.
• Oversee defense counsel and request the use of private field investigators when necessary.
• Subrogation: aggressively identify, investigate and pursue third-party subrogation recoveries.
• Return to work: assists city and board in identifying and coordinating transitional duty and return-to-work opportunities whenever medically appropriate.
• Legacy files: vendor will assume the administration of all worker compensation claim files including historical.
- Specialized heart and hypertension claims
• Determine legal eligibility and calculate benefits under applicable state statutes.
• Coordinate disability payments with complex statutory caps and offsets.
• Ongoing, sensitive communication with claimants, physicians, and city stakeholders regarding benefit structures.