3.1 Claims Administration The following is a summary of claims administration services that the Consultant will be responsible for performing. a) Receive all First Report of Injuries (FROI) electronically and receive hardcopy supporting claims documentation and convert into a paperless environment; b) The TPA will meet all reporting standards of the City of Cedar Rapids for management reports and for the provision of EDI as specified and required by the IWCC, submit all State and Federal required filings, including IRS Form 1099 and all reporting required by the Medicare Secondary Payer provisions; prepare, maintain and file statistical information required by Rating Bureaus and/or appropriate state agencies to ensure regulatory compliance; c) Perform case investigation; d) Enhanced efforts shall be taken to identify possible fraudulent claims, including recorded statements from injured worker and discussions with witnesses and supervisors; e) Employ the services of outside professionals to assist in investigations, claims adjustments, etc. as necessary. Such services may include, but shall not be limited to surveillance, rehabilitation, claim specific medical care managers and subject matter experts. The use of such services shall only be with prior written approval by the City; f) Coordinate the medical treatment of all claims by promptly setting appointments and authorizing necessary physician referrals and treatments; g) Claims adjudication; h) Setting and revising case unfunded liability levels (reserves); i) Telephonic and Field Case management by Registered Nurses which require travel and on-site meetings with claimants and providers; j) Timely and accurate claims processing by the TPA; k) Integration (through the Finance Department with the City’s staff) on the resolution of cases, and assessing the return to work program; l) Development, maintenance and expansion of, and steerage to, the occupational health and pharmacy network; m) Review and provide reports to the City regarding all medical bills and other services for which a claim is being made for reasonableness and conformity to appropriate medical and surgical fee schedules and network discounts; n) Timely processing of benefit payments to claimants, medical providers and other miscellaneous vendors according to state mandated guidelines; o) Responsible for the review of medical, pharmacy and hospital bills and applying the Iowa fee schedule as well as any network negotiated discounts; p) Prepare and maintain electronic files as necessary for legal defense of claims and or other litigation (such as actions for subrogation) or other proceedings; q) Advise the City when defense attorney assignment is necessary on a file; the City shall approve and designate any assigned counsel. The TPA shall provide the defense attorney a complete copy of the file in question when an assignment is made; r) Attend workers' compensation hearings, depositions when required, and mediations on behalf of the City; s) Report to the various excess carriers (based on each carrier’s reporting requirements) potential and excess claims. The TPA shall reimburse the City for any late reporting penalties imposed by the carrier due to failure on the part of the TPA; t) Provide all status reports, as required by the excess carrier(s); and u) Submit requests to any excess carrier(s) for all payments above each claim's Self-Insured Retention to obtain the proper reimbursement for the City. The reimbursement checks shall be forwarded to the City and the amount recovered shall be entered into the TPA’s claims information system. Upon request by the City, the TPA shall provide a current report of all claims where excess money is outstanding. Requests should be submitted within 45 days of payments in excess of the self-insured retention.
