1. Staffing The TPA is responsible for providing sufficient and competent staffing to fulfill the contractual requirements. The City will require at least one senior claims examiner assigned to its account. The senior examiner(s) will be State Certified, have at least five (5) years of indemnity claims experience, three (3) years of which includes public agency experience with public safety officers. Each examiner shall have an average caseload not to exceed 150 open indemnity claims. Claims assistants shall have an average caseload not exceed 200 open medical only claims. The supervisor shall have a caseload not to exceed 75 open indemnity claims. 2. Forms The TPA shall provide all forms necessary for the processing of benefits or claims information including the Employer's Report of Injury, Division of Workers’ Compensation (“DWC”) Form 1, medical service orders, return to work slips, lost time information reports, vouchers, checks, and other related forms. These forms shall be provided electronically upon request. The cost of providing these forms shall be included within the contract price. 3. Claim File Set Up and Diary Review Upon receipt of the Employer's Report of Injury, the TPA will prepare an individual claim file within one (1) working day for each claim. Initial investigation shall be completed within 14 days from the day of receipt of each claim, with additional time for further investigation as reasonably needed. Initial plan of action shall be clearly documented in the claim file within 14 days from receipt of the claim. The claim file shall include notes regarding potential exposure, disposition plan, financial transactions, and other relevant information. All claim files shall be reviewed at least every thirty (30) days for active claims and at least every six (6) months for claims that have settled but are open for the employee's future medical care. The examiner shall distinguish the regular diary review from routine file documentation in an electronic system accessible to City. The supervisor shall monitor the diary reviews by printing a "No Activity" report each month to identify any files that have fallen off the diary system.
