5-Attachment B Scope of Work.docx

TJ26-7 Third Party Insurance Advisement

SCOPE OF WORK

Third-Party Claims Handling Services

1. Purpose The purpose of this Request for Proposals (RFP) is to solicit proposals from qualified contractors to provide third-party claims handling services for property and liability claims on behalf of the Department of Risk Management (DORM) within the State of Utah. The State of Utah intends to award contracts to the four (4) highest scored Responsive and Responsible vendors capable of providing professional claims management services across the State of Utah.

The resulting contracts will provide the DORM with experienced claims professionals capable of receiving claim assignments, conducting investigations, documenting findings, and supporting claim resolution activities. Contractors must maintain a local operational presence within the State of Utah and be able to respond on site within forty-eight (48) hours of claim assignment when required.

2. Background The DORM is responsible for managing claims arising from property damage and liability exposures associated with its operations throughout the State of Utah. These claims require timely investigation, documentation, and evaluation to ensure appropriate resolution and protection of public resources.

To support these efforts, the DORM seeks to establish contracts with qualified third-party claims administrators (TPAs) or claims handling firms that have experience working with government entities and the State of Utah. These contractors will supplement the DORM’s internal claims management capabilities by providing professional investigative and claims management services on an as-needed basis.

Maintaining a local Utah footprint is essential to ensure rapid response, familiarity with state regulations, and the ability to conduct prompt on-site claim investigations.

3. Scope of Services The Contractor will provide professional third-party claims handling services for property and liability claims assigned by the DORM, including all of the following but not limited to.

3.1 Claims Intake and File Setup

· Receive claim assignments from the DORM.

· Establish and maintain claim files for each assigned claim.

· Acknowledge receipt of claim assignments within the timeframe established by the DORM.

3.2 Claims Investigation

· Review incident reports and supporting documentation.

· Interview claimants, witnesses, and involved parties.

· Gather relevant documentation and evidence.

· Photograph damage or incident locations when applicable.

· Document findings in written reports.

3.3 On-Site Investigations

· Maintain the capability to conduct on-site claim investigations throughout the State of Utah.

· Respond within forty-eight (48) hours of claim assignment when field investigation is required.

3.4 Claims Evaluation

· Evaluate liability and damages based on collected evidence.

· Provide professional analysis and recommendations regarding claim disposition.

· Identify potential exposure or risk factors associated with the claim.

3.5 Coordination and Communication

The Contractor shall coordinate with:

· DORM representatives

· Claimants

· Witnesses

· Contractors or service providers

· Other relevant parties involved in the claim Contractors will maintain clear and timely communication with the DORM throughout the claim investigation process. Monthly updates are expected with more timely updates as pertinent claims events arise on a weekly basis.

3.6 Claim Resolution Support

· Provide written recommendations regarding claim disposition, including settlement or denial.

· Assist the DORM in gathering documentation necessary for claim resolution or litigation preparation if necessary.

3.7 Geographic Coverage

Contractors are expected to be able to provide services throughout the State of Utah in every county and municipal.

3.8 Exclusions

Unless specifically authorized by the DORM, the following activities are outside the scope of this contract:

· Providing legal representation.

· Making final settlement determinations on behalf of the DORM unless expressly authorized.

· Developing or modifying DORM policies.

Services may be requested throughout the State of Utah and will be performed on an as-needed basis during the contract term.

4. Contractor Qualifications and Requirements

4.1 Minimum Qualifications

Offerors must demonstrate the following:

· Experience handling property and liability claims.

· Experience providing claims services for government entities or public sector clients.

· Operational capability within the State of Utah.

· Ability to perform on-site investigations within forty-eight (48) hours of claim assignment.

4.2 Licensing and Certifications

A valid Utah Adjuster license is required or a valid out of state adjuster license that qualifies for reciprocity with the state of Utah.

4.3 Staffing

Contractors shall maintain adequate staffing levels to ensure timely response to claim assignments and investigations.

4.4 Confidentiality

Contractors must protect confidential information and maintain secure records in accordance with The Privacy of Consumer Financial and Health Information (Rule R590-206), Utah Protection of Personal Information Act (Utah Code 13-44), Claims File Confidentiality (Utah Code 31A-26-306, Public Adjuster Specifics (Rule R590-274), Unfair Claims Settlement Practices (Utah Code 31A-26-303) and DORM policies.

4.5 Meetings and Coordination

Contractors may be required to participate in:

· Coordination meetings

· Case review meetings

· Contract performance reviews as requested by the DORM.

5. Performance Standards and Compliance Contractor performance will be monitored to ensure compliance with contract requirements.

5.1 Response Time

Contractors must respond to requests for on-site investigation within forty-eight (48) hours of claim assignment.

5.2 Timeliness

Contractors are expected to perform investigations and submit reports within timelines established by the DORM. See 3.5 above.

5.3 Quality Standards

Reports and documentation will be:

· Accurate

· Complete

· Professionally prepared

· Supported by evidence and documentation

5.4 Regulatory Compliance

Contractors must comply with all applicable:

· State of Utah laws and regulations

· Claims handling standards

· DORM policies and procedures

5.5 Performance Monitoring

The DORM may evaluate contractor performance if performance concerns arise based on:

· Responsiveness

· Quality of investigations

· Timeliness of reporting

· Communication with DORM staff

· Compliance with contract requirements Failure to meet performance expectations may result in corrective action or removal from future claim assignments.

6. Deliverables For each assigned claim, the Contractor shall provide the following deliverables:

6.1 Claim Acknowledgement

Confirmation that the claim assignment has been received.

6.2 Initial Investigation Report

A report summarizing:

· Incident facts

· Initial findings

· Preliminary liability analysis

· Photographs and evidence collected

6.3 Status Reports

Periodic updates regarding claim progress when requested by the DORM. See 3.5 above.

6.4 Supporting Documentation

Documentation may include but is not limited too

· Witness statements

· Inspection reports

· Photographs

· Damage assessments

· Other relevant evidence

6.5 Final Claim Report

A final investigation report including:

· Investigation summary

· Liability assessment

· Damage evaluation

· Recommended claim disposition Deliverables shall be submitted electronically unless otherwise directed by the DORM.

7. Contract Term and Timeline The DORM anticipates awarding contracts to up to four (4) vendors with the 4 highest scores Services will be provided on an as-needed basis during the contract term.

Offerors may propose operational timelines for internal claim handling processes within their proposal and will be evaluated accordingly

8. Budget and Historical Usage A specific budget has not been established for this solicitation. Services will be requested on an as-needed basis depending on claim volume and DORM requirements.

Historical claim activity or expenditure information may be provided for informational purposes only. Such information does not constitute a guarantee of future work or minimum contract value.

9. Reference Materials The DORM may provide additional documentation to assist Offerors in preparing proposals, which may include:

· Sample claim report templates

· DORM incident reporting forms

· Claims handling workflow documentation

· Applicable Utah statutes or regulatory guidance

· Additional operational guidance These materials may be included as attachments to the solicitation.