The vendor is required to provide that insurance claim review and audit services for to review claims files managed by state fund third party administrator (TPA) pursuant to its discretionary purchasing authority under state finance law.
- Vendor will be provided the following:
• Access to the workers’ compensation board electronic case folder and read only access to a TPA’S web-based claims program for the purpose of performing claim reviews;
• A spreadsheet that will include information relevant to the claims to be reviewed;
• Material specific to agency reserving guidelines and procedures; and
• TPA “best practices” manual.
- Vendor’s responsibility:
• The vendor will review all of the information made available on each case selected for review and:
o Offer a recommendation as to what the indemnity (compensation) and medical incurred losses should be for each case reviewed and present same on the spreadsheet provided;  
o Provide a concise summary of the claim reviewed along with a rationale for the incurred values recommended (to include calculations);  
o Provide direction/guidance on claims handling issues if warranted;
o Re-evaluate recommendations if provided with additional information from TPA;  
o Prepare a summary report to include statistical information on incurred losses and Findings/recommendation;   
o Verify that reserve recommendations are reflected in the TPA claims program and report to agency reserve recommendations not adhered to;
o Verify that claims handling recommendations are addressed by TPA and report to agency recommendations that are not adhered to.
- Contract Period/Term: 5 years